Recent Articleshttp://prospect.org/authors/126070/rss.xml
The American Prospect - articles by authorenA New Strategy for Health Carehttp://prospect.org/article/new-strategy-health-care
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><em>This article appears in the Winter 2018 issue of </em>The American Prospect <em>magazine as part of a joint project with the Century Foundation on <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://tcf.org/content/event/health-reform-2020/&amp;source=gmail&amp;ust=1515078413315000&amp;usg=AFQjCNHzwDFSjPBXHgO_UnUWwQ7-PYaY9A" href="https://tcf.org/content/event/health-reform-2020/" target="_blank"><strong>Health Reform 2020</strong></a>.</em></p>
<p><em><a href="http://www.prospect.org/subscribe"><strong>Subscribe here</strong></a> to </em>The American Prospect<em>. </em></p>
<p></p><div class="media media-element-container media-default"><div id="file-32763" class="file file-image file-image-jpeg">
<h2 class="element-invisible"><a href="/file/hc2020logo-04jpegjpg-0">hc2020_logo-04_jpeg.jpg</a></h2>
<div class="content">
<img height="61" width="109" style="margin: 10px; float: right;" class="media-element file-default" data-delta="1" alt="" title="" src="http://prospect.org/sites/default/files/hc2020_logo-04_jpeg_0.jpg" /></div>
</div>
</div>
<p><span class="dropcap">W</span>ith the Trump era only a year old and its full impact on health policy as yet unclear, it may seem premature to discuss what ought to come next. But, driven by new enthusiasm among progressives for Bernie Sanders’s single-payer plan, the debate has already begun, and if the past is any indication, supporters of reform will turn to proposals long in gestation when they are finally able to act.</p>
<p>When that time comes, Democrats don’t want to discover they have locked themselves into commitments on health care that they cannot fulfill, just as Donald Trump and Republicans did in 2016. Democrats are justifiably angry today about the Republican efforts to sabotage the Affordable Care Act and cut Medicaid that have put health care for millions of people in jeopardy. Supporters of a universal system also have good reason to believe that the ACA was too limited and a stronger government role is necessary. But going to the opposite extreme and nationalizing health insurance has its own problems. Even by Sanders’s own estimate his plan would require a larger increase in federal taxes than the United States has ever had in peacetime. For that reason alone (and there are others), Democrats need to look at a broader menu of alternatives.</p>
<p>So, imagine it is January 2021, and a Democrat is ready to assume office as president along with a new Democratic Congress: What priority should health care get, and what policies should a new administration push for?</p>
<p>In Trump’s wake, many other legitimate concerns will be clamoring for attention and resources. For four years, the Trump administration will have neglected and in some cases aggravated America’s real problems, including economic inequality and insecurity, climate change, and the decaying public infrastructure that Trump shows no signs of fixing. The two previous Democratic presidents made health care their top priority for reform in their first year. Although Bill Clinton failed to pass his Health Security Act, Barack Obama succeeded in passing the ACA. But both of them faced a backlash driven in part by their health policies, lost Democratic congressional majorities after two years, and from then on faced severe limits on what they could accomplish.</p>
<p>I supported Clinton’s and Obama’s decisions to make health care the early focus of reform in their presidencies, but I’d be hard-pressed to make that argument a third time. That’s not to say the Democrats’ presidential candidate in 2020 should ignore or downplay health care. The Trump era’s damage to national health policy will call for an answer, and the party’s primary voters care intensely about the answer their nominee will give. Democrats, however, ought to learn from experience and focus on health-care priorities that make sense as both policy and politics and build popular support over time. Those priorities will have to deal with core concerns about health care yet not absorb every last dollar of revenue a new administration might hope to raise.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_17319734540162.jpg?itok=lSjLrYIu" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(Bill Clark/CQ Roll Call via AP Images)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Senator Debbie Stabenow of Michigan has taken a leading role in support of making a Medicare buy-in available at age 55.</p>
</div>
</div>
</div>
</div>
</div>
<p>Repairing whatever is left of the ACA, if anything is left, will be important but insufficient. Although the ACA has gained in popularity since Trump’s election, the law’s limitations have also become increasingly apparent. A new Democratic administration should focus on one or two signature health-care proposals that advance the long-term objectives of universal coverage and cost control and respond to people who have insurance but still face financial stress from medical bills. Two ideas could meet these criteria: making available a new Medicare plan for people aged 50 to 64—a program I call “Midlife Medicare”—and directly attacking America’s excessive health-care prices. Although the two ideas are independent, they’re closely related, since attacking prices also involves an extension of Medicare, in this case the extension of Medicare rates to out-of-network providers in private insurance.</p>
<p> </p>
<h3>Limits of the ACA</h3>
<p>Advocates for broader access to health care have rightly defended the ACA from Republican attacks, but facing up to its limits is crucial for figuring out what to do next. The law has worked well, but it hasn’t worked well enough. From 2010 to 2016, it cut the proportion of Americans without health insurance almost in half, from 16.3 percent to 8.8 percent, and it did that without causing the economic havoc that opponents predicted. But it hasn’t effectively addressed the underlying problem of rising costs and consequently hasn’t assured a stable and affordable system. Although millions have received care they wouldn’t have gotten, Gallup data indicate that 29 percent of Americans—37 percent of women compared with 22 percent of men—still put off medical treatment due to cost in 2017, not significantly different from before the ACA. While seeing improvements in the scope of coverage such as the elimination of annual and lifetime caps, many Americans with private insurance now face much higher deductibles than in the past. The sense of many people who previously had good health benefits that their own insurance is deteriorating may account for much of the dissatisfaction with the ACA.</p>
<p>Moreover, the two means by which the ACA has extended health insurance—the expansion of Medicaid and reform of the individual insurance market—ran into problems even before Trump took office. Some of those difficulties stem from the Supreme Court’s decision about Medicaid and red-state resistance to the program, while others reflect limitations of the ACA itself, now aggravated by Trump’s policies.</p>
<p>In 2012, when the Supreme Court made the ACA’s Medicaid expansion optional for the states, it put in question an incremental strategy for expanded coverage that reformers had followed for more than two decades. In the 1980s, Congress began increasing Medicaid eligibility for low-income pregnant women and children. If states wanted to get any federal funds for Medicaid (and all states did), they had to cover the new beneficiaries and services that federal law mandated. Congress thereby gradually ratcheted up a program that originally covered only special groups among the poor—the disabled, blind, aged, and single-parent families on welfare. But many low-income people continued to be left out of Medicaid, especially in Southern states that severely restricted eligibility.</p>
<p>In 2010, the ACA took the next step in turning Medicaid into a general health-care program for low-income people by extending eligibility to all those with incomes up to 138 percent of the federal poverty level. (In 2017, that’s $16,643 for an individual.) The new national standard would have gone into effect in 2014 if the Supreme Court had not ruled—for the first time since Medicaid’s enactment in 1965—that Congress could not condition all federal Medicaid funds on a state’s agreement to include a new group of beneficiaries.</p>
<p>The Court’s decision hasn’t just allowed 19 Republican-led states to reject the ACA Medicaid expansion; it also prevents Congress in the future from ratcheting up national standards for Medicaid coverage as it did in the past. Indeed, the ratchet now will work in the other direction. If Republicans cut the traditional Medicaid program when they are in power, Democrats cannot later restore coverage, much less expand it, and count on states being effectively required to comply.</p>
<p>Leaving Medicaid coverage up to the states has a big impact on low-income people who live in Republican areas. During the first half of 2017, the share of adults aged 18 to 64 who were uninsured was 19 percent in the states that did not expand Medicaid, compared with 8.8 percent in the states that did.</p>
<p>Although Medicaid will continue to be central to financing health care, it is hard to see how it can serve as a firm basis for universal coverage. Democrats can reduce reliance on Medicaid, however, by shifting to the other national framework for coverage established in 1965—Medicare. Many of Medicare’s original supporters hoped to use it eventually to cover everyone, and in 1972 Congress extended it to cover those on disability insurance as well as patients with end-stage renal disease. By incrementally expanding Medicaid in the 1980s and then creating the Children’s Health Insurance Program (CHIP) in 1997, Congress was able to offload some of the cost of expanded coverage onto the states. With that route to a universal system now effectively cut off, reformers need to turn back to Medicare, which as a national program doesn’t give Republicans in the states a veto point. As a result of its popularity and success in both controlling costs and providing broad access to providers, <span class="pullquote">Medicare also has other advantages that make it a stronger platform than Medicaid for the next phase of health-care reform.</span></p>
<p> </p>
<p><strong>BESIDES EXPANDING MEDICAID,</strong> the ACA has increased coverage by helping people afford private insurance. Instead of trying to restructure all private insurance and put a lid on its total costs—as the 1993 Clinton health plan had sought to do—the ACA leaves employer-based health plans for the most part unchanged and focuses primarily on reforming the individual (or “non-group”) market.</p>
<p>Before the ACA went into effect in 2014, insurers priced policies for individuals according to the beneficiaries’ health and age and limited the scope of coverage through caps and exclusions, including the exclusion of pre-existing conditions. People who bought insurance directly on their own got poor value for money, and millions of individuals remained uninsured because they couldn’t afford the rates, were deemed uninsurable, or took the risk of going without coverage and depending on charity care if they got seriously ill.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/7029981403_2c557bf429_o.jpg?itok=KwoQ2nQO" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(LaDawna Howard/Flickr)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>A rally in support of the Affordable Care Act in front of the Supreme Court in March 2012</p>
</div>
</div>
</div>
</div>
</div>
<p>The ACA deals with these problems through new rules and new subsidies. While allowing for considerable patient cost-sharing, the new rules require insurers to cover all applicants for a list of “essential health benefits” at rates not based on their health and only to a limited extent based on their age. A financial penalty for failing to carry a minimum level of coverage—the so-called “individual mandate”—was supposed to motivate the healthy to insure, deterring people from opportunistically buying insurance only when they needed it. The new sliding-scale tax credits for premiums, available only through state-based marketplaces, go to people with incomes up to four times the federal poverty level, while subsidies for deductibles and co-pays go to insurers for the benefit of people with incomes up to 250 percent of the poverty line.</p>
<p>After an encouraging start in 2014, the individual-market reforms look increasingly inadequate. The premium tax credits have been too low and the penalty for failing to insure has been too small and too weakly enforced to get many healthy people to sign up. The unpopularity of the individual mandate made it a perfect point of attack for Republicans against the whole structure. Insurers have been able to skirt the requirement to sell individual policies at the same community rate by designing separate plans to be sold outside the state marketplaces to lower-risk individuals (a problem that Trump’s policies will exacerbate). Some supporters of the ACA had expected the marketplaces to work so well that they would become a desirable alternative to employer-based insurance. Instead, because of limitations in their design, the marketplaces suffer from adverse selection (disproportionately high-cost enrollment), and the plans they offer typically provide access to a more limited list of doctors and hospitals than Medicare or a good employer plan provides.</p>
<p>The problems of high prices and limited insurance options have intensified in the past year as major insurers have dropped out of many of the ACA’s marketplaces. In much of the country, only a single insurer offers coverage, and rates have soared as a result. Lacking even a fallback public option—a public insurance plan triggered by the lack of private competition—the enrollees in the marketplaces have had to settle for whatever remains available to them.</p>
<p><span class="pullquote">In retrospect, the ACA has neither been generous enough (in its subsidies) nor tough enough (in the individual mandate) nor realistic enough about the market (in its lack of a public option).</span> But the biggest limitation of the ACA’s market reforms is that they don’t address the underlying problems in health-care prices.</p>
<p> </p>
<h3>It’s the Prices, Stupid</h3>
<p>In 2016, the United States devoted nearly 18 percent of national income to health care, compared with about 11 percent for peer countries such as Germany, France, and Sweden and an average of 9 percent for the 35 member nations of the Organization for Economic Cooperation and Development. Although national health spending generally rises with per capita income, the United States is an outlier, spending vastly more on health care than its per capita income predicts. The excess is not the result of Americans going to the doctor or hospital more often or using more drugs or generally consuming more medical services than people in the other economically advanced societies. The single biggest factor is that Americans pay higher prices for health care, as Gerard F. Anderson, the late Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan argued in a 2003 article in <em>Health Affairs</em> memorably titled “It’s the Prices, Stupid.” It is the price system, particularly for patients with private insurance or no coverage, that lies at the heart of the cost problem of the American health system.</p>
<p>While other countries regulate health-care prices or budgets, the United States leaves prices in the private market to insurers and providers, a system that has failed to create any effective check on what providers charge. The sources of market failure arise from the structure of health care and insurance and from trends toward monopoly power that have made a bad situation worse.</p>
<p>Health-care spending is concentrated—I realize this is shocking—among the very sick. In any given year, the most costly 10 percent of a population typically accounts for about two-thirds of total costs. When people face serious health problems, they often have urgent needs and ties to particular physicians that limit their practical options. It’s not realistic to expect most patients in those circumstances to shop around and compare prices, and even if they tried, they usually wouldn’t be able to find out beforehand how much different hospitals and other providers would charge.</p>
<p>Imagine if buying gas for your car worked like hospital care. If it did, when you pulled into a gas station, no prices would be posted. What you’d pay would depend on your car insurance, but no one could tell you what those prices or the total cost would be. It would depend on what several different mechanics—not all of whom would necessarily be “in-network”—determined your car needed. The bill would be incomprehensible, and most of it would be paid by your employer’s plan. Eventually, the full cost would come out of the wages you and your fellow employees were paid, although you wouldn’t be able to do anything about it. One thing we could say for sure: Gas prices would be very high under this system.</p>
<p>In the mid-1990s, when managed care was on the rise, insurers did hold down prices and costs for a while, but the effect was short-lived. Partly in response to managed care, health-care providers at the local and regional level began consolidating into massive health systems that have enabled them to regain market power and jack up prices. Consolidation has also taken place on the insurer side and in other segments of health care, such as pharmacy benefit managers, all to the disadvantage of consumers. Insurers have passed on higher provider costs to employers, who have passed them on their workers, with the sharp increase in deductibles being one of the consequences.</p>
<p><span class="pullquote">The one relatively bright spot in the American system has been the Medicare program, which has a system of federally set prices.</span> That system, although far from perfect, has kept down Medicare costs relative to private insurance yet still preserved access to nearly all doctors and hospitals for Medicare beneficiaries. So, just as we should think about using Medicare to achieve universal coverage, we should also think about expanding the use of Medicare prices to control costs and sustain a universal system.</p>
<p> </p>
<h3>The Case for Midlife Medicare</h3>
<p>In her 2016 presidential campaign, Hillary Clinton had policies on nearly every issue confronting the country, while Trump had only a few simple positions. Clinton’s nuanced command of the issues was admirable, but many voters were unsure what she would do as president, whereas everyone knew exactly what Trump was promising. If Democrats learn one thing from Trump’s success, it should be focus. While candidates ought to have extensive and detailed knowledge, they need a small number of easily grasped focal ideas that define what their candidacy is all about. With that concern in mind, I am suggesting only two focal points for an agenda in health care—making a new part of Medicare available to people at age 50 and controlling health-care prices. Although the details will be complicated to work out, people won’t need to be experts to understand what they stand to gain from those policies.</p>
<p>Recent Republican alternatives to the ACA hit older adults in the individual market particularly hard. The legislation passed by Republicans in the House in May would have allowed insurers to charge older adults five times as much as younger adults (instead of three times as much under the ACA) and would have provided much smaller premium subsidies with little adjustment for income. According to the Congressional Budget Office, in a state that carried out the law without any special waivers, the House bill would have raised the net cost of insurance for a 64-year-old with an income at 175 percent of the federal poverty level from $1,700 to $16,100—an 847 percent increase. In September, Republicans in the Senate fell one vote short of passing their own repeal-and-replace legislation, which would have converted all premium subsidies as well as funds for the Medicaid expansion into block grants to the states. Under that bill, if Republican-led states adopted the same principles that their representatives in the House supported, older adults now getting marketplace coverage would also have faced such radical increases in premiums that many of them would have become uninsured. Since Republicans keep promising to carry out their policies one way or another—through federal legislation, administrative waivers, and state policies—the threat to older adults has not disappeared.</p>
<p>Older adults are particularly concerned about health insurance because of the onset of health problems in midlife. Moreover, as the economists Anne Case and Angus Deaton have shown, rates of illness and death have been increasing in recent decades for Americans in midlife, especially for non-Hispanic whites with a high school education or less. The human costs of deindustrialization are being recorded in their lives. For many of them, finally becoming eligible for Medicare at age 65 is a moment of tremendous financial relief.</p>
<p>The idea of moving that age up to 55 through an early “buy-in” to Medicare has been around since President Clinton proposed it in 1998. In 2017, a group of Democratic senators, led by Debbie Stabenow of Michigan, introduced a bill for a Medicare buy-in beginning at age 55, while a group of Democrats in the House proposed a buy-in starting at age 50. But reform efforts haven’t focused on the potential of the buy-in idea, and there has been no recent effort to cost out the different ways of designing it. The term “buy-in” may suggest an option wholly financed by premiums, but since many of the people interested in early access to Medicare will have retired before age 65 because of health problems, a program entirely financed by premiums would be unaffordable.</p>
<p>Midlife Medicare, as I imagine it, would be a new part of Medicare for people aged 50 to 64, financed by general revenues as well as by premiums. The general revenue would be set roughly to offset adverse selection and to match the value of subsidies in the ACA, scaled up for a standard Medicare plan, including pharmaceutical coverage. (Like Medicare Part B, it would not draw on the Medicare Trust Fund.) The program would be open to older adults who do not have employer-sponsored insurance and were not offered it, and it would consequently be smaller and more fiscally manageable than a single-payer plan. Yet it would still be an important breakthrough not only for the people who would enroll in it but for others as well because it would significantly reduce costs for the remaining, younger pool in the individual market.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_17208753007771.jpg?itok=uUEMdfZN" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(AP Photo/Alan Diaz)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>After an encouraging start in 2014, the reforms to the individual health insurance market look increasingly inadequate.</p>
</div>
</div>
</div>
</div>
</div>
<p>Focusing on Midlife Medicare would respond to political realities that advocates of “Medicare for all” have hoped to elide. Shifting all Americans into a federally financed program, as I mentioned earlier, would require a staggering increase in taxes. Advocates say that because of savings people would pay less than they do now in premiums, but this argument ignores several problems. First, many people such as seniors and veterans who are satisfied with their coverage would see the new taxes as an extra burden. Second, employees with health benefits would have to trust that their employers would pass along savings in the form of higher wages and that the resulting wage increases would offset the new taxes—an impossible calculation for them to make. Third, a single-payer plan would require people to give up their current private coverage, and as long experience has shown, Americans are fearful of doing so, especially once a mobilized private health-care industry has had a chance to raise anxieties about change. Single-payer proposals have gone down to defeat in state referenda three times in recent decades: 73 percent to 27 percent in California in 1994, 79 percent to 21 percent in Oregon in 2002, and 80 percent to 20 percent in Colorado in 2016—all blue states, and the margins were not even close.</p>
<p>General expansions of Medicare, such as Jacob Hacker’s proposal for a new part of Medicare open to everyone (including employee groups), would also raise concerns about open-ended costs and risk alienating a crucial group—seniors. Many of the elderly see Medicare as their own program, earned through taxes they have paid over their working years, a view they have long been encouraged to hold by Medicare advocates. Midlife Medicare would have a far better chance of winning seniors’ support. The leading organization representing seniors, AARP, welcomes all Americans 50 years of age and older as members and seeks to represent them as a single constituency. People aged 50 to 64 have also paid Medicare taxes over their working years and can equally be said to have earned Medicare benefits. Since Social Security already has a provision for obtaining pension benefits early (at age 62), the idea of early eligibility is a familiar one. Public opinion data on a Medicare buy-in for 55- to 64-year-olds are encouraging. According to an April 2017 YouGov survey, seniors approve a Medicare buy-in at nearly as high a rate (71 percent) as all age groups combined (82 percent).</p>
<p>Americans who resist publicly financed health care in the abstract often seem more willing to support it when the issue is more specific to an age group. That is how we got Medicare and CHIP. Age-based public programs may not be ideal, but they are not an intolerable compromise. They have the political virtue of creating an identifiable group of beneficiaries whose problems are readily understood and whose families can be mobilized to defend their rights.</p>
<p>Like “senior” Medicare itself, Midlife Medicare would likely receive support from those too young to enroll who would see it not just as someone else’s protection but as someday their own. People with an employer-sponsored plan would know that if they decide to retire early, they could continue to get good health coverage. By removing older adults from the individual market—in effect, siphoning off much of the high-cost population—Midlife Medicare would also make premiums for younger people more affordable. An additional step, eliminating the two-year waiting period for Medicare currently facing people already deemed eligible for Social Security Disability Insurance, would contribute to still-lower premiums in the individual market for the population age 49 and younger.</p>
<p><span class="pullquote">Politically, Midlife Medicare represents a possible point of convergence between the left and center in the Democratic Party.</span> Advocates of Medicare-for-all might support an extension of Medicare to age 50 as a first step toward their larger goal, while others could see it as a positive step on its own. Even if Midlife Medicare didn’t lead to any further expansions of Medicare, it could help show how to make the rest of the system work better. Here it’s important to understand why the Medicare program works better than the ACA and how the latter might be fixed with the benefit of Midlife Medicare’s example.</p>
<p> </p>
<p><strong>SEVERAL DIFFERENT IDEAS</strong> for expanding Medicare are now in circulation. A key distinction among them is whether they involve expanding Medicare as a plan or Medicare as a program. The distinction is crucial.</p>
<p>When most people think of expanding Medicare, they think of expanding access to the public Medicare plan, as in Sanders’s single-payer, “Medicare for all” bill. But the Medicare program is not actually a single-payer; a third of beneficiaries use it to sign up for one of the many private Medicare Advantage plans. Medicare is now a framework for choice of plan—a marketplace for public-private competition. Expanding use of that framework has distinct advantages over the ACA marketplaces, even if the latter included a public plan.</p>
<p>It’s not only Sanders’s single-payer bill that calls for expanding the use of Medicare as a plan rather than Medicare as a program. Some public-option proposals do the same. Senators Michael Bennet and Tim Kaine have proposed a new Medicare plan, which they call Medicare “X,” for “extra,” that would be offered as an option in the ACA’s individual marketplaces, beginning in 2020 with counties that have one or no private plans, extended three years later to all individual marketplaces, and the following year to small business. The Medicare-X plan would meet the ACA’s requirements for essential health benefits and be financed through premiums, supported by the same subsidies as other marketplace plans.</p>
<p>Medicare-X has advantages over public options that are supposed to be “like Medicare” but unconnected to the Medicare program itself. If stand-alone public plans had to negotiate rates with providers, the plans might not have much bargaining power, and even if they used Medicare rates, many providers might refuse to participate. But participation in Medicare-X at Medicare rates could be required of providers who want to continue participating in “senior” Medicare, as nearly all would. If Bennet and Kaine’s proposal had been part of the ACA, it might have averted some of the problems in the marketplaces today. But, as an adjustment to the ACA, it also reflects some of the law’s limitations.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/shutterstock_144337669_0.jpg?itok=gHpKT4Mv" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(Christian Delbert/Shutterstock)</div>
</div>
</div>
</div>
</div>
<p>To appreciate those limitations, consider the differences between the framework for choice of plan in the Medicare program and in the ACA. The key differences have to do with how plans pay health-care providers, and how much consumers pay for different plans. The federally set provider prices for public Medicare also effectively cap what private Medicare Advantage plans pay providers. In Medicare Advantage, out-of-network providers are paid no more than Medicare rates and are prohibited from billing beneficiaries for any additional amount (so-called “balance billing”). As a result, in-network providers have an incentive to offer insurers even lower prices in order to get an increased number of patients.</p>
<p>The result is that the Medicare market is similar to European health systems that have multiple insurance funds but more unified payment rates. Even though the cap on out-of-network charges in private plans may seem a small detail of Medicare, it achieves a large effect in protecting Medicare beneficiaries from rising costs.</p>
<p>The other key aspect of Medicare is the dominant role of Medicare’s public plan. Public Medicare doesn’t just offer an “option”; public Medicare’s costs are the basis (or “benchmark”) for determining how much beneficiaries pay for Medicare Advantage plans. But while public Medicare covers roughly 80 percent of expected average costs for beneficiaries, the benchmark in the ACA marketplaces is the second-lowest-cost “silver plan,” which covers only 70 percent of expected average costs. For the same level of coverage, ACA beneficiaries pay a lot more themselves. The difference has had a huge impact on the plans in the ACA marketplaces that consumers choose. The system has driven enrollees toward plans with relatively high deductibles and narrow networks and generated only ambivalent support for the program. In addition, the complete cut-off of subsidies for people with incomes above four times the poverty level has also created a significant group of middle-class people who don’t have their premiums capped and often resent the ACA for forcing them into a risk pool and plans that require them to pay more for insurance than they previously did.</p>
<p>In contrast to the insurer monopolies in many ACA marketplaces, the terms established by Medicare give seniors access to both an affordable public plan and a variety of private options. The Medicare system works as well as it does because it has both a dominant public plan and price regulation on the private side. In contrast, Kaine and Bennet’s Medicare-X proposal calls only for a public plan as an option in the ACA marketplaces, not the price regulation that enables private plans to compete in Medicare Advantage. Insurers will argue that they cannot compete with Medicare-X under those circumstances, and they’re probably right. Although it may seem ideologically inconsistent, insurers need price regulation (that is, of providers) in order to compete with a public plan that sets rates.</p>
<p>Midlife Medicare would have all the features that enable Medicare to work better than the ACA—the strong public Medicare plan, the use of that plan as a benchmark, and provider price regulation in private Medicare Advantage options. All those elements would come as part of the now-established Medicare structure. Reformers could also try to introduce these features into the ACA marketplaces if the ACA survives the Trump era.</p>
<p>But regardless of what happens with the ACA, one idea deserves wider consideration as a general cost-control measure: using Medicare rates to cap out-of-network charges in private insurance.</p>
<p> </p>
<h3>The New Case for Regulating Prices</h3>
<p><span class="pullquote">Health-care reformers and political leaders need to take a new look at an old idea—price regulation in health care. </span>As of 1980, more than 30 states regulated hospital rates, but during the following two decades nearly all of them eliminated rate-setting in the belief that managed care and the free market would solve the problem of high health-care costs. Instead, prices and costs have continued to rise to far higher levels than in other peer countries, and waves of consolidation in the health-care industry have created monopoly provider systems in many areas. Relying on the market to limit health-care costs was never likely to work, but it is even more implausible today than it was before.</p>
<p>The new case for price regulation isn’t based only on the growth of monopoly power in health care. After 30 years of unregulated private rates and regulated Medicare rates, the evidence is in: Medicare has held down prices more effectively than private insurance. The use of Medicare rates as a cap on out-of-network charges in Medicare Advantage has also demonstrated the value of a limited but strategic intervention to control costs without imposing uniform price controls. A legitimate concern about traditional price regulation is that it would lock in the fee-for-service payment system. But a cap on out-of-network fees still allows insurers to work out contracts that reward in-network providers for better performance. Out-of-network caps can be a spur to moving the entire health-care system away from fee-for-service. The Obama administration began moving public Medicare itself toward alternative payment methods, and while those methods have so far not yielded big savings for Medicare (and are being eroded under Trump), they have created the basis for a payment system that combines cost containment with incentives for improvements in the quality of care.</p>
<p>Capping out-of-network charges would also hardly be an unpopular idea. At a time when deductibles have been rising and patients are often hit by “surprise” medical bills (for example, from an out-of-network physician at an in-network hospital), provider payment caps would directly address problems that even the relatively well-insured are facing. The out-of-network caps then would also constrain in-network costs, since they would reduce the bargaining power of the monopoly systems.</p>
<p>Out-of-network prices could be limited in two general ways. Direct regulation based on Medicare rates would be the stronger approach. Commercial rates for hospital care today vary from roughly 130 percent to 200 percent of Medicare; one estimate puts the average for hospital prices at about 175 percent of Medicare. According to a study of private insurance claims by Yale University’s Zack Cooper and colleagues, applying Medicare rates to all private insurance would reduce total private spending on inpatient hospital care by 31 percent. If the cap were set at 110 percent of Medicare, spending would drop by 24 percent; if at 130 percent of Medicare, spending would fall by 11 percent. Hospitals have generally been doing very well lately, with average margins of around 7 percent; nonprofit hospitals are a very profitable business. Even so, simply extending Medicare rates would be too severe. A somewhat higher cap—perhaps varying by region, and gradually tightening over time—would be an effective way to keep costs down.</p>
<p>A second approach would be to require hospitals to follow Medicare’s relative prices and post a single figure indicating where they stood in relation to Medicare. For example, one hospital might choose to offer care at Medicare rates, another at 130 percent of Medicare, and a third at 200 percent of Medicare. Insurers have not had success in controlling costs by providing their subscribers with tools for price transparency. As I suggested earlier, many patients are not in a position to shop around. But a simplified system based on Medicare ratios might have a significant impact, if only because of the force of public opinion on the institutions charging the highest prices. If it’s too difficult to reinstitute rate-setting, requirements for simple transparency would be a good second choice.</p>
<p> </p>
<p><strong>WHENEVER DEMOCRATS GET</strong> another shot at health reform, that effort will have to fit within a larger national agenda and other demands facing the country. My proposals for Midlife Medicare and price regulation are a guess about what might be both desirable and feasible at that point. If the ACA marketplaces survive in a weakened form, Midlife Medicare could help reduce the burdens on them and demonstrate how a restructured marketplace with a strong public plan can work. If Republicans have succeeded in destroying the ACA, it may be hard to persuade people to revive that model, and Midlife Medicare could offer another practical way forward, as CHIP did in the wake of the defeat of the Clinton health plan.</p>
<p>Since the lower health-care costs of other countries are mainly the result of more effective price restraint, we could get a lot of the benefit of single-payer from adopting caps on provider payment. But price regulation doesn’t have to wait for a change in national politics. State governments could undertake that function as they once did, focusing now on out-of-network charges as a key point of leverage. State experiments with different strategies for regulating health-care prices could then prove valuable for policy at the national level.</p>
<p>Of course, the struggle over preserving the gains of the ACA isn’t over. States may be able to step in to make up for some of the Republican sabotage at the national level. But it is also not too soon to think about the alternatives that lie ahead when new opportunities for reform emerge.</p>
</div></div></div>Thu, 04 Jan 2018 10:00:06 +0000229243 at http://prospect.orgPaul StarrAn American Way for America Nowhttp://prospect.org/article/american-way-america-now
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/unitedwewin.jpg?itok=dA5xTHUF" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">National Archives/Public Domain</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Many of the efforts promoting national unity in the World War II era left out blacks—but not this poster from 1942, which encouraged racial tolerance among factory workers.</p>
</div>
</div>
</div>
</div>
</div>
<p><em>This article appears in the Fall 2017 issue of </em>The American Prospect <em>magazine. <a href="http://www.prospect.org/subscribe">Subscribe here</a>. </em></p>
<p><span class="dropcap">A</span>mericans often look back to the mid-20th century as a time when the country was cohesive and unified, unlike today’s bitterly divided society. That image of mid-century America was always incomplete, but insofar as there was a culture of consensus, it was not a wholly spontaneous development. Much of the country’s leadership and national media from the 1930s through World War II and the early postwar years made concerted efforts to foster unity across social and religious lines in the face of threats from abroad and at home to America’s stability and survival.</p>
<p>The United States is surely different today—the lines of cleavage have shifted, the media have fractured into separate worlds, and we have a president who acquired power with explicitly anti-immigrant and racist appeals. But the mid-20th century experience nonetheless offers instructive lessons for confronting the divisions that endanger America now.</p>
<p>National unity in the mid-20th century, as the historian Wendy L. Wall argues in her book Inventing the “American Way,” was a political project that came in several different varieties. While Franklin D. Roosevelt and the New Deal promoted a pluralistic and economically inclusive vision, corporate leaders championed free enterprise and class harmony as “the American way,” a phrase introduced into the political lexicon through an advertising campaign by the U.S. Chamber of Commerce in the late 1930s. Rather than question whether there was an American way, other groups sought to appropriate the idea. In a world with anti-Semitism and other hatreds on the rise, interfaith groups promoted the American way as the ability of people with different religious beliefs to live together. The fall of France to the Nazis in 1940 was widely interpreted as evidence of the danger of a divided society, and when the United States entered the war, it became a national imperative to encourage mutual tolerance and cooperation. A month after Pearl Harbor, FDR warned: “Remember the Nazi technique. ‘Pit race against race, religion against religion, prejudice against prejudice.’”</p>
<p>Wall points out a key difference between the elites who promoted civility and tolerance and others, including those on the left, who put equality at the center of their vision. The former ignored power imbalances, while the latter “tried to use the language of consensus to correct them.” As Wall says, the efforts to define a national consensus “gave religious, ethnic, and racial ‘outsiders’ a powerful lever with which to pry open some doors of America’s mainstream culture.” White ethnics made considerable progress in getting through those doors; African Americans, not so much, at least not in the New Deal, which to its great shame perpetuated black exclusion and disenfranchisement.</p>
<p>Overcoming that failure became the concern of the civil rights movement and liberal reforms of the 1960s, which in turn gave rise to the politics of white backlash that we have been living with ever since. The pattern isn’t new; every advance African Americans have made since slavery and Reconstruction has generated a backlash. America seems forever caught in a racial loop, in which efforts to escape from racism repeatedly expose how deep it runs and set off new bursts of hatred. Other groups also face prejudice, but the situation of African Americans is historically distinct. Racial slavery was a singular evil lasting more than two centuries, and overcoming its long aftereffects poses singular demands for tenacity in the struggle for justice. As frustrating as the reversals in that struggle have been, we have surely come too long a way to make Donald Trump’s election a final verdict on America’s possibilities.</p>
<p>The renewed growth and tremendous diversity of America’s immigrant population, another development dating to the 1960s, add to the challenge of America’s racial legacy. While the new immigrants have enlarged the nonwhite base of Democratic support, they have also intensified the politics of white grievance and backlash. Faced with right-wing xenophobic attacks on immigrants, many of us are drawn to a general defense of all the foreign-born in the country. But distinctions are necessary. The young Dreamers who grew up here and know no other country ought not to be confused with those who may have come recently as adults and overstayed their visas. To be in favor of protecting Dreamers and providing a path to citizenship for the long-resident undocumented does not imply an indiscriminate forgiveness, much less support for “open borders.” America owes all people within its jurisdiction certain fundamental human rights, including due process of law, but its primary obligations are to its citizens. No political party can expect to win majority support if it fails to make clear the primacy of those obligations.</p>
<p>Since Trump’s victory, Democrats have been arguing about how to win back a majority, a discussion that has focused on attracting white voters, especially working-class whites. The attention to whites makes some progressives and African Americans uneasy, as it suggests deemphasizing racism and such issues as police accountability. Their concern is understandable. From the Constitutional Convention to the end of both Reconstruction and the civil rights era, black interests were sacrificed in the name of national unity and political expediency. So this much must be clear: <span class="pullquote-right">The cause of racial equality is too central to liberal values to be sacrificed again.</span></p>
<p>But neither can progressives ignore the need to win white voters in the belief that a growing nonwhite population will eventually make lost white support irrelevant. If that day ever comes, it is a long way off, and in the meantime Republicans will use every means at their disposal to stop it from coming at all. Nonwhite voters are also so geographically concentrated that winning more of them will not be sufficient to achieve majorities in state legislatures and Congress anytime soon. So regaining more white support is not optional either for Democrats or for African Americans and other minorities who depend on Democrats for a voice, unless they want to resign themselves to indefinite rule by an increasingly right-wing Republican Party.</p>
<p>Since Republicans have been winning white majorities for some time—Trump only extended the pattern—the challenge may look impossibly difficult. But Democrats don’t have to win a majority of whites, only enough whites to win majorities overall. In that case, some suggest, why not just focus Democratic efforts on more affluent and highly educated whites, many of them in suburban districts that have been trending Democratic? Isn’t the preoccupation with working-class whites just an outdated impulse?</p>
<p>To be sure, Democrats need to win more votes wherever they can get them, but where and how they win those votes will affect the kind of policies they can carry out. Focusing attention on affluent whites will increase internal strains in a Democratic Party that generally supports progressive taxation and other redistributive policies and continues to enjoy more support from lower-income minority voters and unions. If Democrats are going not just to maintain their tradition of economic progressivism but to advocate it more forcefully, they need to devote energy and resources to building support among working-class voters, white as well as nonwhite. And since African Americans benefit when Democrats are able to enact economically progressive policies like universal health coverage, they have a big stake in the success of that kind of coalitional politics.</p>
<p> </p>
<p><strong>THE SUCCESS OF THAT </strong>politics is vital to future possibilities for the country, not just the Democrats. Bringing America together is as important now as it was in the mid-20th century, but the real question is on what terms. Trump’s terms are clear. The implicit reference in his slogan, “Make America Great Again,” is the America that fully incorporated white, working-class ethnics but not blacks or more recent immigrants. It’s a vision of unity that not only fails to anticipate the future—it doesn’t account for the America that already exists today.</p>
<p>As in the mid-20th century, however, there is more than one alternative for a broadened vision. We can try to bring Americans together on the basis of civility and tolerance, or go further and pursue a more ambitious ideal of equality. Don’t get me wrong: Civility and tolerance are essential in their own right. Without them a good society is impossible. But the unity we need in America ought to be based on more than tolerance; it ought to reflect a commitment to equality, and those who believe in that ideal ought to promote a politics that can sustain it.</p>
<p>To be sure, the old New Deal coalition, with its base in industrial unions, can’t be resurrected. The post-industrial economy, however, breeds its own deep dissatisfactions, and the remedies Trump offers don’t respond to them at all. The growing problems of precarious employment, the hyperconcentration of new businesses and job growth in the largest metropolitan areas, the excessive power of platform monopolies in the new online economy, disparities in income that Republican tax and budget changes will only exacerbate, out-of-control health-care prices—these are some of the items that ought to be on a new agenda for economic fairness and inclusion that the Democrats alone are in a position to take up.</p>
<p>With Trump as president, the Republicans are now fully invested in an aging, almost entirely white electoral base and the politics of white grievance. In what turned out to be a fateful call to the Prospect’s co-editor Bob Kuttner on August 15, Steve Bannon said he would be happy to have Democrats “talk about racism every day. If the left is focused on race and identity, and we go with economic nationalism, we can crush the Democrats.” Of course, Bannon himself has his own identity politics—white identity politics. And his version of economic nationalism would leave displaced coal miners and industrial workers no better off. But Democrats should take Bannon’s words as a challenge to show that they can continue to address racial injustice and still win enough votes from whites by framing a vision of national prosperity and a decent society that all Americans will see as the country they want to live in.</p>
<p>Even at their best, the mid-20th century versions of the American way weren’t fully inclusive, and they couldn’t possibly anticipate the economic and social changes that the next half-century would bring. But they did have one thing right. They encouraged Americans to see themselves as sharing a common culture and common fate. They promoted solidarity. That solidarity now has to reflect a multiracial and egalitarian vision, not a backward-looking exclusive one. A crucial feature of the American way is that it hasn’t been static and unchanging. We have an elastic, living tradition, and we need to make sure it continues expanding to keep up with all the people who make America their home and who must work together for the country to work at all.</p>
</div></div></div>Wed, 01 Nov 2017 09:00:00 +0000228508 at http://prospect.orgPaul StarrAfter Comey, Congressional Republicans Totally Control Trumphttp://prospect.org/article/after-comey-congressional-republicans-totally-control-trump
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_17157772038704.jpg?itok=Wjv5SRoZ" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(AP Photo/Pablo Martinez Monsivais)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>From left, Senate Majority Whip John Cornyn, Senate Majority Leader Mitch McConnell, House Majority Leader Kevin McCarthy, House Speaker Paul Ryan, White House adviser Jared Kushner, Deputy National Security Adviser Dina Powell, Treasury Secretary Steven Mnuchin, and House Majority Whip Steve Scalise wait in the Roosevelt Room of the White House for a meeting with President Trump and Vice President Pence on June 6, 2017.</p>
</div>
</div>
</div>
</div>
</div>
<p><span class="dropcap">F</span>ormer FBI Director James Comey’s testimony may have seemed like a boon to Democrats, but it has another effect that has been little commented on: Donald Trump is now totally dependent on congressional Republicans to avoid impeachment and therefore has no choice but to be a cheerleader for their policies and to sign whatever legislation they send him.</p>
<p>When Trump was nominated, many people accepted his own self-characterization as a disruptive force within the Republican Party. But the party itself had already moved toward more extreme positions, and Trump’s cabinet appointments, proposed budget, moves toward economic and environmental deregulation, and repudiation of the Paris climate accord have been largely in line with the radicalism that now prevails among congressional Republicans.</p>
<p>But if there were any thought that Trump would defy the Republican majorities in Congress—insisting, for example, on a health-care bill that actually protected many of the people who voted for him—that is now clearly out of the question. Congressional Republicans will stand by him as long as he advances their agenda. If he becomes a hindrance, they can begin impeachment proceedings with what will likely be compelling evidence provided by the special counsel. Mike Pence will be waiting to take over.</p>
<p>Trump, to be sure, will never act like the little political lamb he must now become. He will remain personally volatile and unpredictable, continually threatening to break out of the cage he has put himself in and pressing for pet causes like the border wall. But on the big questions, we are in for a period of congressional government.</p>
<p><span class="pullquote-right">All the focus on Trump as an extremist has indirectly had the effect of minimizing how extreme congressional Republicans have become.</span> When the health-care bill in the House of Representatives first went down to defeat because of opposition from the right-wing Freedom Caucus, there was a lot of talk about the influence of Republican moderates. But the final bill that passed the House with the support of the Freedom Caucus was more extreme than the earlier bill, and enough moderates went along with the party leadership to enable it to pass.</p>
<p>That House bill is now the basis of the legislation Republicans in the Senate are working on entirely behind closed doors and without any public hearings so as to provide Democrats and the public no opportunity to object. We are already hearing about the influence of Republican moderates in the Senate, even though they have apparently accepted the framework of the House bill, which will eliminate not just the expansion of Medicaid but the basic Medicaid entitlement and deprive millions of other people of the private insurance that they gained through the Affordable Care Act.</p>
<p>When Trump signs that legislation—as I expect he will in September—he will herald it as a great victory, the fulfillment of his party’s and his own pledge to repeal and replace Obamacare. This is exactly why at the Senate hearing where Comey made his devastating charges, Republicans pretended not to see the evidence of obstruction of justice. For the time being, they have no interest whatsoever in initiating proceedings against the president that would consume their agenda. They know they have Trump in a position where he has no real choice except to do what they want.</p>
<p>That’s not to say Trump is incapable of doing something self-destructive, as he has been wont to do. But if he has a basic sense of political self-preservation, he will take his cues from Paul Ryan and Mitch McConnell and act as their faithful servant.</p>
</div></div></div>Fri, 09 Jun 2017 14:08:56 +0000227860 at http://prospect.orgPaul StarrA True Republican Health-Care Unravelinghttp://prospect.org/article/true-republican-health-care-unraveling
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_17083731722731.jpg?itok=2p_x2PC5" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Andrew Harnik</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>House Speaker Paul Ryan pauses during a news conference on Capitol Hill in Washington, Friday, March 24, 2017. </p>
</div>
</div>
</div>
</div>
</div>
<p><em>The following article, which appears in the Spring 2017 issue of The American Prospect under the title “The Republican Health-Care Unraveling: Resist Now, Rebound Later,” went to press on Tuesday, March 21, before the Republicans gave up on their health-care bill and pulled it from a vote. But while the first section of the article is now moot (at least for the time being), the second part (“Blocking Trump’s Chaos Option”) and the third (“The Next Progressive Health Agenda”) are pertinent to what happens next. - P.S., March 24, 2017.</em></p>
<p><span class="dropcap">I</span>magine if Donald Trump had been a genuine populist and followed through on his repeated promises to provide health insurance to everybody and take on the pharmaceutical and insurance industries. Populists in other countries have done similar things, and Trump might have consolidated support by emulating them.</p>
<p>Of course, Trump’s promises about health care weren’t any more genuine than his promises about Trump University. But even if he had been in earnest, he would have still faced a problem. Unlike right-wing populists elsewhere, Trump did not come to power with a party of his own or well-developed policies. He came tethered to the congressional Republicans, entirely dependent on them to formulate and pass legislation. That dependence will likely complicate Trump’s ambitions in such areas as trade policy. But nothing so far has made more of a mockery of Trump’s populism than the health-care legislation introduced in early March by Paul Ryan and the House Republican leadership and fully backed by Trump.</p>
<p>The Ryan bill is abhorrent for many reasons. It calls for a massive tax cut for people with high incomes, while costing millions of other Americans—24 million by 2026, according to the Congressional Budget Office—their health coverage. It would turn Medicaid from a right of beneficiaries into a limited grant of funds to the states, and it pays for the tax cuts for the rich with cuts in health care for the poor. The bill’s reduced tax credits for insurance make no adjustment for low income, while some credits would go to people with incomes over $200,000.</p>
<p>But what is most amazing about the bill is how badly it treats constituencies and states that voted for Trump and the GOP. The changes it calls for in the individual insurance market would hammer older people (those between the ages of 50 and 64) and residents of red states and rural areas. Republicans appear to be so determined to cut taxes on top incomes that they are willing to sacrifice the interests not only of the poor—we knew that—but of many of their own voters. The same pattern is evident in the federal budget that Trump has proposed.</p>
<p>While the whole effort to “repeal and replace Obamacare” poses an enormous political risk for Republicans, it presents an equally significant political opportunity for liberal and progressive Democrats. I am not talking only about short-term resistance to the Republican rollback of the Affordable Care Act. Now that Republicans have shown their true hand on health care, they are creating new possibilities for long-term progressive organizing and policy alternatives.</p>
<p>The struggles to achieve health insurance for all in the United States have long suffered from one fundamental political handicap. The uninsured and underinsured (people enrolled in plans riddled with exclusions and limits) have been an inchoate population without any organization or voice of their own. The combination of measures America adopted in the mid-20th century produced a large, protected public: employees with good fringe benefits, seniors and the disabled with Medicare, veterans, and the low-income groups that qualified for Medicaid. The people who were left out—mainly low-wage workers, people in part-time work, the unemployed, and individuals with pre-existing conditions—did not share a common identity or cohere politically.</p>
<p>But the Republican effort to undo the ACA could provide the long-missing organizational impetus. <span class="pullquote-right">It is one thing to go without health insurance; it is another thing to have that insurance threatened or taken away.</span> It also matters who would be losing coverage. Overall, according to the CBO, the Ryan bill would raise the number of uninsured in 2026 to 52 million, or 19 percent of the nonelderly population (compared with a projected 10 percent under the ACA). But the uninsured under Ryan’s legislation would be concentrated among 50- to 64-year-olds. That’s primarily because the bill would allow insurers to charge 60-year-olds five times as much as 20-year-olds, instead of the 3-to-1 ratio in the ACA. (The adjustments for age in the bill’s tax credits do not come close to offsetting the higher premiums; a last-minute amendment, allowing increased tax deductions for medical expenses, provides little or no benefit to low-income people but may be changed in the Senate.) When twenty-somethings don’t have insurance, many give it little thought because they may not expect to need medical care. But older people aren’t so oblivious. Take away their health insurance, and they are going to be angry.</p>
<p>Besides pushing a lot of older people out of coverage, the Ryan bill is brutal on states with high health costs because it would provide a flat tax credit that doesn’t vary according to geography (unlike the ACA, which provides greater subsidies in high-cost states to make coverage affordable). The Ryan bill’s tax credits are substantially smaller on average than those in the ACA, but people in high-cost states would face especially sharp increases in premiums because of the way the bill structures its tax credits.</p>
<p>According to an analysis by the Center on Budget and Policy Priorities, Ryan’s bill would reduce premium tax credits by more than half in Alaska, North Carolina, Oklahoma, Alabama, Nebraska, Wyoming, West Virginia, Tennessee, Arizona, South Dakota, and Montana. The net cost of insurance would rise dramatically as a result. Notice something about those states? They elect a lot of Republicans—or at least they did.</p>
<p>Within states, rural areas generally have higher premiums than urban areas. So the flat tax credits provide less help in affording insurance there, too. The big Medicaid cuts that Republicans are calling for will also have a severe impact in rural areas. The resulting declines in coverage will force some rural hospitals and clinics to close, with spillover effects on middle-class people who depend on the same facilities and services.</p>
<p>Ryan and other House Republicans have touted one CBO finding: After initially increasing insurance premiums, their bill would reduce premiums after 2020 compared with the ACA. But that’s because their measure would force so many older people to drop coverage that the average age of the insured population would drop. It’s nothing to be proud of. Trump and the Republicans promised more coverage and lower costs when they replaced Obamacare. It is now transparently obvious that they can’t deliver on that promise and that they are willing to deny health insurance even to millions of people who voted for them.</p>
<h2><strong>Blocking Trump’s Chaos Option</strong></h2>
<p>If Trump and the Republican Congress cannot pass legislation this year, they do have a fallback option. They can claim that the ACA is collapsing and make sure that it does. Then they can return to health-care legislation later and say they have no choice except to repeal Obamacare. This is the option Trump at times has seemed to prefer. “Let it be a disaster, because we can blame that on the Dems,” he told the National Governors Association on February 27. “Let it implode, then let it implode in 2018 even worse. … Politically, I think it would be a great solution.”</p>
<p>When Trump talks about Obamacare imploding, he is talking not about the entire program (although he seems to think so), but rather one specific part: the insurance exchanges in the individual market. The danger he and other Republicans invoke is a “death spiral”—a situation where rising premiums drive the healthy out of the market, forcing premiums up and more healthy people out, until the market fails. The exchanges are nowhere near that point. Although rates in the exchanges did rise sharply in 2016, they rose to the level originally projected by the CBO (premiums had come in lower than expected earlier). Moreover, the vast majority of individuals who buy insurance in the exchanges receive subsidies that cap the cost of their premiums; many of them also receive subsidies covering a share of deductibles and co-pays. Consequently, as the CBO and other studies have found, the exchanges have some protection against a death spiral—as long as the subsidies are fully funded and the individual mandate is enforced.</p>
<p>But the insurance exchanges could soon face a dire crisis because the Trump administration has created uncertainty for both insurers and enrollees about the survival of the program and enforcement of the mandate. If the administration doesn’t enforce the mandate—or if Congress eliminates the penalty for failing to insure, as the House bill would do for this year—the incentive for healthy people to pay for coverage will fall, threatening the viability of the market.</p>
<p><span class="pullquote-right">Some damage has already been done.</span> As soon as the Trump administration came into office, it canceled outreach efforts in the final phase of the open-enrollment period for 2017. Since individuals who enroll early tend to be those who know they will have high medical costs, while late enrollees are a healthier group, the cutoff of late outreach not only reduced total enrollment but also led to a higher-cost pool. The Trump administration is also proposing to shorten the open-enrollment period for 2018.</p>
<p>Other measures the administration favors could encourage insurers to stay in the market, albeit with mixed effects on enrollees. The administration wants to tighten up special enrollment outside of the open-enrollment period, which may well be justified; it also proposes requiring people to pay any unpaid premiums before enrolling for the next year. In a step that would help keep premiums down, the administration has encouraged states to seek waivers to develop reinsurance programs for the individual market, as Alaska has already done. (Reinsurance spreads the cost of high-cost cases across the entire market.) Alaskans buying insurance individually faced a possible 40 percent rate increase because of 37 very high-cost cases, accounting for one-quarter of claims. The reinsurance measure adopted by the state, using funds from an existing premium tax, kept premium increases by Premera Blue Cross, the sole insurer in Alaska’s exchange, to 9.8 percent.</p>
<p>Insurance companies need to indicate by June whether they will offer coverage in the exchanges for 2018. Uncertainty about the rules is a recipe for chaos. If they believe the mandate will not be enforced, they are likely to jack up premiums or withdraw entirely from the market. About a third of the exchanges, mainly in rural areas, have only one carrier offering coverage this year; additional withdrawals for 2018 could create just the kind of crisis that Trump and the Republicans need as a pretext to undo the ACA.</p>
<p>This problem has a ready solution. If Republicans in Congress do not replace the ACA for the coming year, the Trump administration needs to make clear that it will enforce the law as it stands for 2018 and fully fund the program (including cost-sharing subsidies). Moreover, Republicans cannot plead there is no way to strengthen the individual market. The Ryan bill contains a Patient and State Stability Fund of $100 billion over ten years that the CBO believes states would use largely to cover high-cost enrollees in the individual market and thereby prevent a death spiral. In the absence of comprehensive new legislation, Congress should provide those funds in a separate measure to stabilize the market for 2018. The Republicans cannot blame a collapse on Democrats when they have it in their power to maintain coverage for the millions of people who depend on the market now.</p>
<h2><strong>The Next Progressive Health Agenda</strong></h2>
<p>Even as they resist the Republican rollback of the ACA and Medicaid, Democrats should be thinking about new initiatives in health care. No doubt the next steps will depend in part on what Trump and the Republicans end up doing. In the wake of federal legislation, many of the critical decisions in the short run may move to the states. But Democrats cannot limit themselves to defensive efforts to salvage the ACA at either the federal or the state level. They need to think about a more attractive national agenda in health care that reflects the lessons of the ACA and new political realities.</p>
<p>The coming national Democratic debate is going to focus on extending Medicare—to whom, how quickly, and under what rules will be the questions. The strategy for universal coverage in the ACA relied on the extension of Medicaid for the poor, but the limitations of that approach should now be clear. In its 2012 health-care ruling, the Supreme Court effectively made it impossible to use Medicaid as a foundation for universal coverage. As a mixed federal-state program, Medicaid affords states the opportunity to limit coverage, and the ACA experience has shown how far red states will go in doing that. Republicans may also succeed in eliminating Medicaid’s status as an entitlement, which will be hard to restore.</p>
<p>As a national program with deeper public support as an entitlement and no role for the states, Medicare does not suffer from these problems. When Medicare was enacted in 1965, its backers hoped to use it to cover other groups besides seniors, and in 1972 Congress did extend it to the disabled and patients with end-stage renal disease. (The disabled become eligible for Medicare two years after they qualify for federal disability insurance, a delay that leaves many people with high costs in the individual market.) But the expansion of Medicare then stopped, and in the 1980s Democrats in Congress obtained Republican support for incremental expansions of Medicaid to cover low-income pregnant women and young children. This was the path that led to the ACA’s further Medicaid expansion, a strategy that the Supreme Court and Republicans have now brought to an end.</p>
<p>Many people will equate an expansion of Medicare with a “single-payer” plan. But even Medicare-for-all would not be a single-payer system since about one-third of current Medicare beneficiaries use the program to buy coverage in a private Medicare plan. Medicare today is a marketplace—but a marketplace with a dominant public plan and not just a “public option,” which might turn out, if badly designed and established separately from Medicare, to be a relatively small and weak player in the market.</p>
<p>Medicare-for-all faces two enormous obstacles. Moving everyone under age 65 into Medicare would require a huge increase in taxes; employees who now receive health care as a fringe benefit would inevitably look at those taxes as an additional burden, even if reformers try to assure them that their wages would rise once health care was financed by taxes.</p>
<p>Moreover, many seniors insist that Medicare is their program, and they fear—or can be made to fear—that extending the program to others will jeopardize their coverage. They also see Medicare as an earned benefit, and many of them resist extending it to people who they believe haven’t earned it.</p>
<p><span class="pullquote-right">But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation.</span> My name for this new program is “Midlife Medicare,” which would be open to people age 50 to 64 not otherwise insured (for example, by an employer). Seniors would be more likely to accept this extension than any other; for one thing, AARP welcomes as members all Americans 50 years of age and older. Earlier versions of this idea have been referred to as a “Medicare buy-in”; I have in mind a program that would be partly financed by taxes and that would automatically provide a basic level of coverage (no mandate needed), which those in midlife could increase by paying income-related premiums (as seniors do now).</p>
<p>Midlife Medicare would have advantages for both its beneficiaries and those age 49 and below remaining in the individual insurance market. The enrollees in Midlife Medicare would benefit from the countervailing power that Medicare exercises. Medicare pays provider rates that are substantially below those paid by private insurers in the non-Medicare market, yet providers accept Medicare patients, who consequently do not face the “narrow networks” in most plans in the individual and small-group markets. Americans who continue to have employer coverage will have the assurance that if they need to retire early, they will have health insurance as good as they would now get at age 65. Midlife Medicare is also a response to the rising death rates and declining health that economists Anne Case and Angus Deaton have demonstrated among non-Hispanic whites in midlife.</p>
<p>Moreover, by pulling the 50- to 64-year-olds out of the individual insurance pool covering people 49 years of age and under, Midlife Medicare would make coverage for the younger population substantially cheaper. The younger enrollees in the individual market would, in effect, no longer be shouldering part of the cost of the more expensive 50- and 60-year-olds. This is a much better way to reduce rates for 20-year-olds than the Republicans’ proposal to let insurers charge 60-year-olds five times as much as young adults.</p>
<p>An additional step to relieve the burden on the individual market would be to eliminate the two-year delay in the eligibility of the disabled for the existing Medicare program. Combining this step with Midlife Medicare and a strong reinsurance program would stabilize and make coverage in the individual insurance market significantly less expensive. With these measures in place, the system could be more or less workable even if Republicans eliminate the individual mandate in favor of a 30 percent premium surcharge on individuals who fail to maintain continuous coverage (as the Ryan bill would do). Although I don’t think that would be a good thing to do, I also don’t think Democrats want to focus their next health agenda on restoring the individual mandate.</p>
<p>Formulating a new health-care agenda requires acknowledging that although the ACA has done much good, it has not worked out as well as its supporters originally hoped. The Supreme Court and the red states have limited how far the strategy could go in achieving health care for all. High deductibles and narrow networks have meant that many people are unhappy with the coverage they are receiving. Trump and the Republicans cynically played on public dissatisfactions, suggesting they would provide something better when, in fact, their alternatives would intensify the problems Americans face. We need to move in a more promising direction that takes into account the difficulties that progressive reform has long faced in health care. Midlife Medicare could be a big next step toward a system that works better for everyone.</p>
</div></div></div>Fri, 24 Mar 2017 20:53:19 +0000227266 at http://prospect.orgPaul StarrThe Next Progressive Health Agendahttp://prospect.org/article/next-progressive-health-agenda
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p> </p>
<div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_17014127612355.jpg?itok=9T6w3FoZ" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Erik McGregor/Sipa via AP Images</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Health-care justice advocates and other grassroots groups gather outside Trump Tower to protest against President Trump's pledge to repeal the Affordable Care Act. </p>
</div>
</div>
</div>
</div>
</div>
<p><em>This is the second part of a two-part article. <a href="http://prospect.org/article/republican-health-care-unraveling">Part I is here</a>. The full version appears in the Spring 2017 issue of The American Prospect under the title: “The Republican Health-Care Unraveling: Resist Now, Rebound Later.” This is the “rebound” part. <a href="http://www.prospect.org/subscribe">Subscribe here</a> to the magazine.</em></p>
<p><span class="dropcap">E</span>ven as they resist the Republican rollback of the ACA and Medicaid, Democrats should be thinking about new initiatives in health care. No doubt the next steps will depend in part on what Trump and the Republicans end up doing. In the wake of federal legislation, many of the critical decisions in the short run may move to the states. But Democrats cannot limit themselves to defensive efforts to salvage the ACA at either the federal or the state level. They need to think about a more attractive national agenda in health care that reflects the lessons of the ACA and new political realities.</p>
<p>The coming national Democratic debate is going to focus on extending Medicare—to whom, how quickly, and under what rules will be the questions. The strategy for universal coverage in the ACA relied on the extension of Medicaid for the poor, but the limitations of that approach should now be clear. In its 2012 health-care ruling, the Supreme Court effectively made it impossible to use Medicaid as a foundation for universal coverage. As a mixed federal-state program, Medicaid affords states the opportunity to limit coverage, and the ACA experience has shown how far red states will go in doing that. Republicans may also succeed in eliminating Medicaid’s status as an entitlement, which will be hard to restore.</p>
<p>As a national program with deeper public support as an entitlement and no role for the states, Medicare does not suffer from these problems. When Medicare was enacted in 1965, its backers hoped to use it to cover other groups besides seniors, and in 1972 Congress did extend it to the disabled and patients with end-stage renal disease. (The disabled become eligible for Medicare two years after they qualify for federal disability insurance, a delay that leaves many people with high costs in the individual market.) But the expansion of Medicare then stopped, and in the 1980s Democrats in Congress obtained Republican support for incremental expansions of Medicaid to cover low-income pregnant women and young children. This was the path that led to the ACA’s further Medicaid expansion, a strategy that the Supreme Court and Republicans have now brought to an end.</p>
<p>Many people will equate an expansion of Medicare with a “single-payer” plan. But even Medicare-for-all would not be a single-payer system since about one-third of current Medicare beneficiaries use the program to buy coverage in a private Medicare plan. Medicare today is a marketplace—but a marketplace with a dominant public plan and not just a “public option,” which might turn out, if badly designed and established separately from Medicare, to be a relatively small and weak player in the market.</p>
<p>Medicare-for-all faces two enormous obstacles. Moving everyone under age 65 into Medicare would require a huge increase in taxes; employees who now receive health care as a fringe benefit would inevitably look at those taxes as an additional burden, even if reformers try to assure them that their wages would rise once health care was financed by taxes.</p>
<p>Moreover, many seniors insist that Medicare is their program, and they fear—or can be made to fear—that extending the program to others will jeopardize their coverage. They also see Medicare as an earned benefit, and many of them resist extending it to people who they believe haven’t earned it.</p>
<p><span class="pullquote-right">But there is a way forward: create a new part of Medicare for the older population below age 65—the older population who have also earned Medicare coverage by paying taxes and who are directly threatened by current Republican legislation.</span> My name for this new program is “Midlife Medicare,” which would be open to people age 50 to 64 not otherwise insured (for example, by an employer). Seniors would be more likely to accept this extension than any other; for one thing, AARP welcomes as members all Americans 50 years of age and older. Earlier versions of this idea have been referred to as a “Medicare buy-in”; I have in mind a program that would be partly financed by taxes and that would automatically provide a basic level of coverage (no mandate needed), which those in midlife could increase by paying income-related premiums (as seniors do now).</p>
<p>Midlife Medicare would have advantages for both its beneficiaries and those age 49 and below remaining in the individual insurance market. The enrollees in Midlife Medicare would benefit from the countervailing power that Medicare exercises. Medicare pays provider rates that are substantially below those paid by private insurers in the non-Medicare market, yet providers accept Medicare patients, who consequently do not face the “narrow networks” in most plans in the individual and small-group markets. Americans who continue to have employer coverage will have the assurance that if they need to retire early, they will have health insurance as good as they would now get at age 65. Midlife Medicare is also a response to the rising death rates and declining health that economists Anne Case and Angus Deaton have demonstrated among non-Hispanic whites in midlife.</p>
<p>Moreover, by pulling the 50- to 64-year-olds out of the individual insurance pool covering people 49 years of age and under, Midlife Medicare would make coverage for the younger population substantially cheaper. The younger enrollees in the individual market would, in effect, no longer be shouldering part of the cost of the more expensive 50- and 60-year-olds. This is a much better way to reduce rates for 20-year-olds than the Republicans’ proposal to let insurers charge 60-year-olds five times as much as young adults.</p>
<p>An additional step to relieve the burden on the individual market would be to eliminate the two-year delay in the eligibility of the disabled for the existing Medicare program. Combining this step with Midlife Medicare and a strong reinsurance program would stabilize and make coverage in the individual insurance market significantly less expensive. With these measures in place, the system could be more or less workable even if Republicans eliminate the individual mandate in favor of a 30 percent premium surcharge on individuals who fail to maintain continuous coverage (as the Ryan bill would do). Although I don’t think that would be a good thing to do, I also don’t think Democrats want to focus their next health agenda on restoring the individual mandate.</p>
<p>Formulating a new health-care agenda requires acknowledging that although the ACA has done much good, it has not worked out as well as its supporters originally hoped. The Supreme Court and the red states have limited how far the strategy could go in achieving health care for all. High deductibles and narrow networks have meant that many people are unhappy with the coverage they are receiving. Trump and the Republicans cynically played on public dissatisfactions, suggesting they would provide something better when, in fact, their alternatives would intensify the problems Americans face. We need to move in a more promising direction that takes into account the difficulties that progressive reform has long faced in health care. Midlife Medicare could be a big next step toward a system that works better for everyone.</p>
</div></div></div>Thu, 23 Mar 2017 09:00:00 +0000227234 at http://prospect.orgPaul StarrThe Republican Health-Care Unravelinghttp://prospect.org/article/republican-health-care-unraveling
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_554353229429.jpg?itok=ik4vlNuZ" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Michael Reynolds/picture-alliance/dpa/AP Images</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Speaker of the House Paul Ryan and House Majority Leader Kevin McCarthy discuss the House Republican's new health-care plan to repeal and replace the Affordable Care Act. </p>
</div>
</div>
</div>
</div>
</div>
<p><em>This is the first part of a two-part article. The full version appears in the Spring 2017 issue of </em>The American Prospect<em> under the title: “The Republican Health-Care Unraveling: Resist Now, Rebound Later.” This is the “resist” part. <a href="http://www.prospect.org/subscribe">Subscribe here</a> to the magazine.</em></p>
<p><span class="dropcap">I</span>magine if Donald Trump had been a genuine populist and followed through on his repeated promises to provide health insurance to everybody and take on the pharmaceutical and insurance industries. Populists in other countries have done similar things, and Trump might have consolidated support by emulating them.</p>
<p>Of course, Trump’s promises about health care weren’t any more genuine than his promises about Trump University. But even if he had been in earnest, he would have still faced a problem. Unlike right-wing populists elsewhere, Trump did not come to power with a party of his own or well-developed policies. He came tethered to the congressional Republicans, entirely dependent on them to formulate and pass legislation. That dependence will likely complicate Trump’s ambitions in such areas as trade policy. But nothing so far has made more of a mockery of Trump’s populism than the health-care legislation introduced in early March by Paul Ryan and the House Republican leadership and fully backed by Trump.</p>
<p>The Ryan bill is abhorrent for many reasons. It calls for a massive tax cut for people with high incomes, while costing millions of other Americans—24 million by 2026, according to the Congressional Budget Office—their health coverage. It would turn Medicaid from a right of beneficiaries into a limited grant of funds to the states, and it pays for the tax cuts for the rich with cuts in health care for the poor. The bill’s reduced tax credits for insurance make no adjustment for low income, while some credits would go to people with incomes over $200,000.</p>
<p>But what is most amazing about the bill is how badly it treats constituencies and states that voted for Trump and the GOP. The changes it calls for in the individual insurance market would hammer older people (those between the ages of 50 and 64) and residents of red states and rural areas. Republicans appear to be so determined to cut taxes on top incomes that they are willing to sacrifice the interests not only of the poor—we knew that—but of many of their own voters. The same pattern is evident in the federal budget that Trump has proposed.</p>
<p>While the whole effort to “repeal and replace Obamacare” poses an enormous political risk for Republicans, it presents an equally significant political opportunity for liberal and progressive Democrats. I am not talking only about short-term resistance to the Republican rollback of the Affordable Care Act. Now that Republicans have shown their true hand on health care, they are creating new possibilities for long-term progressive organizing and policy alternatives.</p>
<p>The struggles to achieve health insurance for all in the United States have long suffered from one fundamental political handicap. The uninsured and underinsured (people enrolled in plans riddled with exclusions and limits) have been an inchoate population without any organization or voice of their own. The combination of measures America adopted in the mid-20th century produced a large, protected public: employees with good fringe benefits, seniors and the disabled with Medicare, veterans, and the low-income groups that qualified for Medicaid. The people who were left out—mainly low-wage workers, people in part-time work, the unemployed, and individuals with pre-existing conditions—did not share a common identity or cohere politically.</p>
<p>But the Republican effort to undo the ACA could provide the long-missing organizational impetus. <span class="pullquote-right">It is one thing to go without health insurance; it is another thing to have that insurance threatened or taken away. </span>It also matters who would be losing coverage. Overall, according to the CBO, the Ryan bill would raise the number of uninsured in 2026 to 52 million, or 19 percent of the nonelderly population (compared with a projected 10 percent under the ACA). But the uninsured under Ryan’s legislation would be concentrated among 50- to 64-year-olds. That’s primarily because the bill would allow insurers to charge 60-year-olds five times as much as 20-year-olds, instead of the 3-to-1 ratio in the ACA. (The adjustments for age in the bill’s tax credits do not come close to offsetting the higher premiums; a last-minute amendment, allowing increased tax deductions for medical expenses, provides little or no benefit to low-income people but may be changed in the Senate.) When twenty-somethings don’t have insurance, many give it little thought because they may not expect to need medical care. But older people aren’t so oblivious. Take away their health insurance, and they are going to be angry.</p>
<p>Besides pushing a lot of older people out of coverage, the Ryan bill is brutal on states with high health costs because it would provide a flat tax credit that doesn’t vary according to geography (unlike the ACA, which provides greater subsidies in high-cost states to make coverage affordable). The Ryan bill’s tax credits are substantially smaller on average than those in the ACA, but people in high-cost states would face especially sharp increases in premiums because of the way the bill structures its tax credits.</p>
<p>According to an analysis by the Center on Budget and Policy Priorities, Ryan’s bill would reduce premium tax credits by more than half in Alaska, North Carolina, Oklahoma, Alabama, Nebraska, Wyoming, West Virginia, Tennessee, Arizona, South Dakota, and Montana. The net cost of insurance would rise dramatically as a result. Notice something about those states? They elect a lot of Republicans—or at least they did.</p>
<p>Within states, rural areas generally have higher premiums than urban areas. So the flat tax credits provide less help in affording insurance there, too. The big Medicaid cuts that Republicans are calling for will also have a severe impact in rural areas. The resulting declines in coverage will force some rural hospitals and clinics to close, with spillover effects on middle-class people who depend on the same facilities and services.</p>
<p>Ryan and other House Republicans have touted one CBO finding: After initially increasing insurance premiums, their bill would reduce premiums after 2020 compared with the ACA. But that’s because their measure would force so many older people to drop coverage that the average age of the insured population would drop. It’s nothing to be proud of. Trump and the Republicans promised more coverage and lower costs when they replaced Obamacare. It is now transparently obvious that they can’t deliver on that promise and that they are willing to deny health insurance even to millions of people who voted for them.</p>
<h2><strong>Blocking Trump’s Chaos Option</strong></h2>
<p>If Trump and the Republican Congress cannot pass legislation this year, they do have a fallback option. They can claim that the ACA is collapsing and make sure that it does. Then they can return to health-care legislation later and say they have no choice except to repeal Obamacare. This is the option Trump at times has seemed to prefer. “Let it be a disaster, because we can blame that on the Dems,” he told the National Governors Association on February 27. “Let it implode, then let it implode in 2018 even worse. … Politically, I think it would be a great solution.”</p>
<p>When Trump talks about Obamacare imploding, he is talking not about the entire program (although he seems to think so), but rather one specific part: the insurance exchanges in the individual market. The danger he and other Republicans invoke is a “death spiral”—a situation where rising premiums drive the healthy out of the market, forcing premiums up and more healthy people out, until the market fails. The exchanges are nowhere near that point. Although rates in the exchanges did rise sharply in 2016, they rose to the level originally projected by the CBO (premiums had come in lower than expected earlier). Moreover, the vast majority of individuals who buy insurance in the exchanges receive subsidies that cap the cost of their premiums; many of them also receive subsidies covering a share of deductibles and co-pays. Consequently, as the CBO and other studies have found, the exchanges have some protection against a death spiral—as long as the subsidies are fully funded and the individual mandate is enforced.</p>
<p>But the insurance exchanges could soon face a dire crisis because the Trump administration has created uncertainty for both insurers and enrollees about the survival of the program and enforcement of the mandate. If the administration doesn’t enforce the mandate—or if Congress eliminates the penalty for failing to insure, as the House bill would do for this year—the incentive for healthy people to pay for coverage will fall, threatening the viability of the market.</p>
<p><span class="pullquote-right">Some damage has already been done. </span>As soon as the Trump administration came into office, it canceled outreach efforts in the final phase of the open-enrollment period for 2017. Since individuals who enroll early tend to be those who know they will have high medical costs, while late enrollees are a healthier group, the cutoff of late outreach not only reduced total enrollment but also led to a higher-cost pool. The Trump administration is also proposing to shorten the open-enrollment period for 2018.</p>
<p>Other measures the administration favors could encourage insurers to stay in the market, albeit with mixed effects on enrollees. The administration wants to tighten up special enrollment outside of the open-enrollment period, which may well be justified; it also proposes requiring people to pay any unpaid premiums before enrolling for the next year. In a step that would help keep premiums down, the administration has encouraged states to seek waivers to develop reinsurance programs for the individual market, as Alaska has already done. (Reinsurance spreads the cost of high-cost cases across the entire market.) Alaskans buying insurance individually faced a possible 40 percent rate increase because of 37 very high-cost cases, accounting for one-quarter of claims. The reinsurance measure adopted by the state, using funds from an existing premium tax, kept premium increases by Premera Blue Cross, the sole insurer in Alaska’s exchange, to 9.8 percent.</p>
<p>Insurance companies need to indicate by June whether they will offer coverage in the exchanges for 2018. Uncertainty about the rules is a recipe for chaos. If they believe the mandate will not be enforced, they are likely to jack up premiums or withdraw entirely from the market. About a third of the exchanges, mainly in rural areas, have only one carrier offering coverage this year; additional withdrawals for 2018 could create just the kind of crisis that Trump and the Republicans need as a pretext to undo the ACA.</p>
<p>This problem has a ready solution. If Republicans in Congress do not replace the ACA for the coming year, the Trump administration needs to make clear that it will enforce the law as it stands for 2018 and fully fund the program (including cost-sharing subsidies). Moreover, Republicans cannot plead there is no way to strengthen the individual market. The Ryan bill contains a Patient and State Stability Fund of $100 billion over ten years that the CBO believes states would use largely to cover high-cost enrollees in the individual market and thereby prevent a death spiral. In the absence of comprehensive new legislation, Congress should provide those funds in a separate measure to stabilize the market for 2018. The Republicans cannot blame a collapse on Democrats when they have it in their power to maintain coverage for the millions of people who depend on the market now.</p>
<p><em>Tomorrow: The Next Progressive Health Agenda</em></p>
<p align="right"> </p>
</div></div></div>Wed, 22 Mar 2017 09:00:00 +0000227218 at http://prospect.orgPaul StarrWho Are We Americans Now?http://prospect.org/article/who-are-we-americans-now
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><em>This article appears in the Winter 2017 issue of The American Prospect magazine. <a href="http://www.prospect.org/subscribe">Subscribe here</a>.</em></p>
<p><span class="dropcap">“</span>That’s not who we are,” Barack Obama often says when appealing to Americans to oppose illiberal policies such as torturing prisoners, barring immigrants on the basis of their religion, and denying entry to refugees. But now that Americans have elected a president who has called for precisely those policies, Obama’s confidence about who we are may seem misplaced. Questions about the defining values of our common nationality have haunted us before at critical moments in American history, and now they do again: In the wake of Donald Trump’s election, what does it mean to be an American? Will Trump and Republican rule change not just how the world sees us but our self-understanding?</p>
<p>National elections create a picture of a people, and they send a signal about changes the voters want. The picture and the signal may be distorted and subject to interpretation, but they cannot be ignored. The 2016 election left many people angry at pollsters for failing to predict the outcome, but it revealed a more serious misapprehension among Democrats and on the left about the future. Eight years earlier, Obama’s victory had seemed to demonstrate the historical inevitability of a more diverse and progressive America, and his reelection seemed to confirm it. Yes, Republicans had their base, but it was old and nearly entirely white. Misleading but widely influential demographic forecasts indicated that the United States was destined to become a majority-minority society. The growing acceptance of LGBT rights, especially among the young, suggested that the cultural backlash against the 1960s was receding. Political analysts interpreted demographic and cultural changes as ushering in an inexorable social and political shift that would favor Democrats and that Republicans would have to accommodate.</p>
<p>A historical perspective should have urged caution. Progressive changes have been arrested before. Alongside the civic, universalistic conception of American identity—the idea that people of any race and religion can come from anywhere in the world and be fully American—there has always been an exclusive view of the country’s core identity as white and Christian. When Americans imbued with that understanding have felt under threat, they have struck back. <span class="pullquote">We cannot be certain that the arc of the universe ultimately bends toward justice, but we do know that for long periods it has been bent the other way.</span> After Reconstruction in the 19th century and the civil-rights struggle a century later, the South—the white South—did rise again. Nothing is guaranteed politically by changes in demography, economics, or culture. Every battle for justice and equality must be fought again and again.</p>
<p>So Trump’s victory may not be the “last gasp” of an old and dwindling white majority. It threatens instead to be a tipping-point event. Although the outcome hung on only a sliver of the electorate in three states, it may produce a disproportionate swing of power to the right and a remaking of American society. Only concerted political action—informed by an accurate understanding of our national situation—can stop that from happening.</p>
<p><span style="font-size: 1.231em; font-weight: bold;">The Shock of Two Impossibilities</span></p>
<p>Before Obama’s election, a black man as president had seemed an impossibility, and before the 2016 primaries, Trump as a major-party nominee, let alone as president, had also seemed an impossibility. Historians decades from now will be asking how these two impossibilities followed one another in immediate succession. If elections create a picture of a people and send a signal about the changes voters want, Americans could not have created two more different pictures of themselves and sent two more different signals than they have now.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap16299733802742.jpg?itok=bcKJiRl9" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/ Evan Vucci</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Supporters of Republican presidential candidate Donald Trump cheer as he arrives to a campaign rally, Tuesday, October 25, 2016, in Sanford, Florida. </p>
</div>
</div>
</div>
</div>
</div>
<p>When the improbable happens, we may have just gotten the odds wrong. When what we believed to be impossible happens, it tells us we were wrong in a more fundamental way, in this case about our fellow citizens. The victories of Obama and Trump, however, sent two conflicting error messages about who we are.</p>
<p>Obama’s victory seemed to demonstrate that, contrary to what we may have thought, the greatest shame in our history might finally be history. Perhaps the American people were willing to judge a man by the content of his character rather than the color of his skin. To those who rejoiced at that thought, Obama’s election was not just a hopeful sign of racial healing but an act of national redemption. It was an event, moreover, of global significance, promising a renewal of America’s reputation for equality and decency in the eyes of the world, a fitting culmination of an era of sweeping worldwide change. Hadn’t the Berlin Wall fallen and South African apartheid ended? Obama’s presidency was one more sign of the triumph of tolerance, pluralism, and democracy.</p>
<p>It would be easier to make sense of Trump’s victory if Obama had become unpopular and the voters were repudiating his administration. As of November, however, Obama enjoyed a healthy approval rating. Nonetheless, Americans elected the very man who spread the birther lie about Obama and came to epitomize the hard-right view that his presidency was illegitimate.</p>
<p>Perhaps Trump’s election shouldn’t have been a surprise. The antecedents can be found in the radicalization of the Republican Party in recent years, and the parallels can be found in the resurgent combinations of populism, xenophobia, and oligarchy in other countries. But Trump’s triumph was shocking because he acted so often in ways that would have sunk any other candidate. He didn’t just disregard the norms of civility, for example, by bragging about the size of his penis and insulting leaders of his own party. He openly appealed to prejudice when he denounced the Indiana-born judge in the Trump University case as a “Mexican” and called for a ban on Muslim immigrants. As he had with the birther lie, he resorted to obvious and outrageous falsehoods such as the claim that Ted Cruz’s father had been involved in John F. Kennedy’s assassination (or the more recent lie that millions voted illegally for Hillary Clinton). He violated the norms of democracy by encouraging violence against protesters at his rallies and refusing to say before the election that he would accept the results.</p>
<p>Trump’s brazenness didn’t just reveal who he is and how he might govern. Of course, we shouldn’t project all Trump’s views onto all those who voted for him. But when Trump’s statements and actions didn’t prove disqualifying, they revealed something first about the Republican Party and then about the voters in November who chose him as president. <span class="pullquote">This was the real shock: Trump’s ability to get away with violating norms against incivility, violence, prejudice, and lying told us something that we didn’t know, or may not have wanted to believe, about America itself.</span></p>
<h3>Which American Story?</h3>
<p>Successful political leaders usually offer a narrative about their country and the world that encourages voters to see them in command. The story about America told by Trump has deep historical roots, though it is fundamentally different from one that Ronald Reagan, the Bushes, the Clintons, and Obama have been telling. Trump’s story is nationalistic, inward-looking, dark, and divisive but well-calculated to mobilize a coalition of the resentful and the opportunistic. His two campaign slogans, “America First” and “Make America Great Again,” each encapsulate that story while attacking those who he implies have betrayed the country and dragged it down.</p>
<p>The plain implication of “America First” is that our political leaders have not been putting the nation first. Although few may have recognized it, “America First” was the name and slogan of the leading isolationist group that before Pearl Harbor opposed going to war against European fascism and Japanese imperialism. Trump’s revival of the phrase was not unrelated to its original use. It highlighted his attack on internationalism, as in the television ad late in his campaign that denounced international bankers and displayed photos of Jewish financiers. “America First” also fit perfectly with his phony charges against the Clinton Foundation as a source of foreign influence when Clinton was secretary of state.</p>
<p>The genius of Trump’s attacks on globally oriented elites is that the 2016 election did include a candidate who owns a global business empire with financial interests abroad that pose unprecedented conflicts of interest in decisions about foreign policy—and that candidate, of course, was Trump. Moreover, Trump’s business is aimed precisely at catering to wealthy global elites. But by dressing himself up as the “America First” candidate, he telegraphed a message about national betrayal directly to people who believe that wealthy global elites have slighted them.</p>
<p>“Make America Great Again” appeals to the same belief that the leaders of the country have failed it and suggests that Trump, a winner himself, will bring that winning game to the nation. At a time when the president was black and a woman was running to succeed him, it hardly needed to be spelled out for Trump’s followers what was great about the past that needed to be restored. While Obama and Clinton symbolized an increasingly diverse America that was increasingly comfortable with its diversity, Trump embodied the discomfort with diversity among whites, particularly men. He artfully summoned up all the smoldering resentments of the Obama years—against blacks, against immigrants, against women, against the media, against “political correctness.” To all those unhappy with the changes since the 1960s, Trump presented himself as their way of taking back America—taking it back to an older, exclusive vision of who Americans are and must continue to be.</p>
<p>It’s tempting to say that there’s nothing new about these ideas.<span class="pullquote"> </span>“America First” and “Make America Great Again” could have been slogans of nativist movements in the 19th and early 20th centuries. <span class="pullquote">We have had a long line of racial and religious originalists who have insisted that America’s greatness stems from its white, Christian founding, rather than from the civic ideals of freedom and equality. </span>The exact lines of conflicts between the forces of closure and those of openness have shifted, but the logic has been the same. When older-stock, native-born whites, typically more small-town and rural, see their power slipping away, they try to shut the gates and reclaim control. That was the impetus behind the immigration restrictions of the 1920s, which were designed to limit the entry of eastern and southern European Catholics and Jews. The same social and cultural forces also typically line up against internationalism and free trade.</p>
<p>Yet, as familiar as Trump’s narrative is, it was not the story about America that recent Republican presidents have told. Reagan was as sunny as Trump is dark. Even when using coded messages to appeal to whites, Reagan and the Bushes stayed within the norms of American politics, declining to incite hostilities, much less violence. The story they repeated was the exceptionalist, civic story of America as a city upon a hill, a beacon of freedom in the world. This is the vision sometimes called the American Creed.</p>
<p>Rhetorically, in fact, there is a more direct line from Reagan to Obama than from Reagan to Trump. Obama has sung the old exceptionalist saga, albeit in a liberal key. Here, for example, is Obama at his second inauguration:</p>
<p style="margin-left:.5in;">…what binds this nation together is not the colors of our skin or the tenets of our faith or the origins of our names. What makes us exceptional—what makes us American—is our allegiance to an idea articulated in a declaration made more than two centuries ago: ‘We hold these truths to be self-evident, that all men are created equal ….’</p>
<p style="margin-left:.5in;">The patriots of 1776 did not fight to replace the tyranny of a king with the privileges of a few or the rule of a mob. They gave to us a republic, a government of, and by, and for the people, entrusting each generation to keep safe our founding creed.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/obama_clinton_rally.jpg?itok=aQBxkD7U" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(Photo: MediaPunch via AP)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>President Barack Obama speaks to a crowd in support of Hillary Clinton at Osceola County Stadium on November 6, 2016.</p>
</div>
</div>
</div>
</div>
</div>
<p>Starting with this familiar invocation of “our founding creed,” Obama then takes the story in a progressive direction:</p>
<p style="margin-left:.5in;">We do not believe that in this country freedom is reserved for the lucky, or happiness for the few. We recognize that no matter how responsibly we live our lives, any one of us at any time may face a job loss, or a sudden illness, or a home swept away in a terrible storm. The commitments we make to each other through Medicare and Medicaid and Social Security, these things do not sap our initiative, they strengthen us. They do not make us a nation of takers; they free us to take the risks that make this country great. …</p>
<p style="margin-left:.5in;">It is now our generation’s task to carry on what those pioneers began. For our journey is not complete until our wives, our mothers and daughters can earn a living equal to their efforts. Our journey is not complete until our gay brothers and sisters are treated like anyone else under the law—for if we are truly created equal, then surely the love we commit to one another must be equal as well. Our journey is not complete until no citizen is forced to wait for hours to exercise the right to vote. Our journey is not complete until we find a better way to welcome the striving, hopeful immigrants who still see America as a land of opportunity—until bright young students and engineers are enlisted in our workforce rather than expelled from our country. …</p>
<p>Obama’s use of the American Creed to make the liberal argument infuriates conservatives. Christopher Scalia, the late Supreme Court justice’s son, writes that when Obama criticizes conservative positions by saying, “That’s not who we are,” he is accusing conservatives of being “un-American.” (Scalia cites a count by a conservative website that Obama has used the line “That’s not who we are” 46 times.) But Obama never questions conservatives’ patriotism or loyalty. When he says, “That’s not who we are,” he is saying, “That’s not who we are when we are at our best. That’s not who we should strive to be.”</p>
<p>Obama’s version of the optimistic, exceptionalist narrative has been a way for him not only to reappropriate it from Reagan, but also to speak for the nation, rather than as a “minority” leader. As a black politician, Obama has continually had to guard against the danger of being seen as representing blacks alone. The American story he has told, beginning with his speech at the 2004 Democratic Convention, has enabled him to lay claim to national leadership. Democrats will need to remember that lesson, especially as they confront the nationalism of the Trump presidency.</p>
<h2>Will Trump Change Us?</h2>
<p>We are now on the verge of one of the greatest U-turns in the history of national policy and politics. It may well change the basic workings of our government and private institutions and the role of the United States in the world. The impact is likely to be profound. Since government is a national looking glass, Americans will see themselves reflected in their government in an altogether different way from the Obama years. Many will look at that reflection and insist, “That’s not who we are.” But to the world—and to many Americans—that is who Americans will be, unless we organize and resist.</p>
<p>When a party controls all three branches of the federal government, it has the power to change society, not just policy. During the past 74 years, Republicans have controlled both Congress and the presidency for only six years (1953–1954, January–May 2001, and 2003–2006). Republicans now have their biggest opportunity since before the New Deal to consolidate a regime of their own making. Largely shorn of their moderate wing, they are a radical party with a radical president, eager to seize a rare moment to undo not only Obama’s legacy but many earlier achievements of Democrats going back three-quarters of a century—and to institute their own regime in ways that will be hard to reverse.</p>
<p>It is a peculiar fact of our political system, but a fact nonetheless, that a president’s loss of the popular vote has no effect whatsoever on his power. The fewer than 100,000 people in Pennsylvania, Wisconsin, and Michigan who gave Trump an Electoral College majority have altered the course of American history—the only question is by how much. The 2016 election was literally a tipping-point election for the Supreme Court. Trump and the Republican Senate can immediately tip the majority back to the Court’s conservatives, and with additional seats likely to be filled, they will probably push the balance further to the right. With little to fear from the Court, Republicans can also pursue more vigorously the course they have already adopted through voter suppression and gerrymandering to make it difficult to vote them out of office. The power of incumbency in American politics is notorious. Since 2010, Republicans have used that power to consolidate their hold on state governments, and they are now poised to entrench themselves federally.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/istock-458411699.jpg?itok=Dqj-eaxg" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Rypson/iStock by Getty</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Onlookers on the National Mall observe the second inauguration of President Barack Obama, January 21, 2013. </p>
</div>
</div>
</div>
</div>
</div>
<p>Many of the policies favored by Republicans for ideological reasons do double duty as means of political entrenchment. Policies weakening labor laws and unions strike at an organizational base of the Democratic Party. Deporting undocumented immigrants who have lived in America with their families for years, instead of providing them a path to citizenship, throws those communities into disarray. Privatizing government transfers not just functions but power and influence to private companies. Turning Medicare into a voucher and Medicaid into a block grant to the states eliminates the rights of beneficiaries under federal law and the role of federal agencies in upholding those rights. Defunding climate science at the Environmental Protection Agency and NASA defunds troublesome climate scientists.</p>
<p>Trump adds another element to the Republican potential for entrenchment. Immediately after the CEO of Boeing criticized Trump’s views on trade in early December, Trump tweeted that it was time to cancel the company’s contract to develop a new design for Air Force One. The message to corporate America was clear—that he would use all means at his disposal to punish any criticism. During the campaign, Trump threatened Amazon founder Jeff Bezos, owner of <em>The Washington Post</em>, with federal investigations because of the <em>Post</em>’s coverage. This is standard practice in populist governments, and not only with respect to the media. Through a combination of favors and threats, the regime turns business into an arm of the state. Republicans were supposed to prefer small government and oppose crony capitalism; they are bringing America the exact opposite.</p>
<p>If Trump does consolidate power in this way, it will have ramifying effects on American thought. Political leaders shape public knowledge and public opinion, even how people think about themselves. Never has more of a bully occupied the bully pulpit of the presidency. <span class="pullquote">Americans identify with winners, and Trump has made winning the supreme good of his public philosophy.</span> Winning governmental power does confer legitimacy as well as power. Those who win power can communicate their view of the world from a privileged, official position. When Trump was mainly known for birtherism, the media could treat him as a political crank. When he steps to the podium to speak as president, he must be accorded the respectful attention due the office. It is the greatest platform for grandiosity and falsehood the world offers.</p>
<p>From that position and the power that comes with it, Trump is going to affect who we are—but it may not turn out the way he intends. After assaulting the norms of American politics during the campaign, he seems a good bet to assault the norms of government and international relations as president. His bluster and recklessness will lead to crises, perhaps to war—and that is where the twin possibilities of Trump’s presidency may become clear. Populist leaders often look to crises as a means of enlarging their powers and suppressing dissent; war especially puts the opposition in the difficult position of appearing unpatriotic if it does not join in cheering on the troops. A people’s sense of their national identity may change in the process.</p>
<p>But crises are also the undoing of governments; leaders who take their countries to war often miscalculate their odds of a quick and easy victory. Crises may arouse a discouraged opposition and enable it to get back on its feet after being knocked down. <span class="pullquote">When reversals of fortune come—whatever the occasion—the opposition must be ready with its own alternatives and its own story.</span></p>
<h2>Remembering Who We Can Be</h2>
<p>Trump and the Republicans now hold the upper hand. But an election in which Trump lost the popular vote by more than 2.7 million does not erase what Obama’s election disclosed about America. The United States is a divided society; many people may wonder whether it is even possible any longer to talk about “we Americans.” Trump’s America and Obama’s America may seem to be two entirely different countries. One and the same nation, however, made Obama its president twice and has now elected Trump, and our common reality is not one choice or the other but the contradiction between them.</p>
<p>Nationally, Democrats have been winning majorities and losing elections. They have won the popular vote for president in six out of the past seven elections since 1992. But that support hasn’t been enough to win sustained power under the American political system. In the two elections in 2000 and 2016 that saw Democrats turn over the White House to Republicans, they have won the popular vote but lost the Electoral College. Clustered on the coasts and in cities, the Democratic vote has also been poorly distributed from the standpoint of controlling the House of Representatives, the Senate, or a majority of the states. The metropolitan clustering of Democratic votes undermines their ability to control the House and state legislatures, and in U.S. Senate elections, Democrats “waste” millions of votes running up big majorities in big states like California and New York. Democrats are now strongest in cities, the weakest part of the federal system.</p>
<p>The Electoral College, the structure of the Senate, and other aspects of the American constitutional system may be unfair, but they are not going to change anytime soon. If Democrats are going to regain power, they will have to broaden their support beyond the constituencies that now support them. They cannot expect salvation from demography even in the long run. Many progressives expect that “people of color” will become a majority and shift the balance of power. The very terminology is misleading. In the 2010 Census, 53 percent of Hispanics who chose one racial category identified themselves as “white” and when Hispanics intermarry with non-Hispanic whites (as 80 percent of Mexican Americans do by the third generation), the children overwhelmingly see themselves as non-Hispanic white. As a result of this pattern of “ethnic attrition” and the likely continued redefinition of who counts as white (and perhaps more important, who counts themselves as white), a majority-minority society will probably be a disappearing mirage.</p>
<p>Democrats have made a bet on being the party of diversity, and there is no going back on it. But they have a choice about how to frame their case. They can tell a story about the struggles of separate and distinct groups—racial minorities, immigrants, women, gays—a list that typically leaves out most white men. Or they can tell a story about America that brings whites in by honoring the country’s traditions as well as by emphasizing common economic and social interests. As Obama has shown, the national story can serve as the frame for contemporary struggles for equality. This is not exactly a rejection of “identity politics.” It is an identity politics of a kind—an effort to ground a majoritarian politics in a shared national identity.</p>
<p>The outcome of the 2016 presidential election wasn’t predetermined by demography, economic conditions, or other circumstances. Clinton might well have won the few additional votes she needed if not for intervention in the election by Russia and FBI Director James Comey. But Democrats still would not have won control of Congress or many of the states, and they will not be able to reverse the regime Trump and the Republicans put in place unless they can win that kind of widely distributed majority. Democrats can hone a much stronger economic message, and they should. They can hope that Republicans fall out and fight among themselves, which they may. But if we are to recover from the damage and national dishonor of Trump’s presidency, Democrats need to appeal to all Americans as Americans and help all of us remember how we can be genuinely proud of our country again.</p>
</div></div></div>Mon, 19 Dec 2016 10:00:00 +0000226546 at http://prospect.orgPaul StarrWhen an Election Damages Democracyhttp://prospect.org/article/when-election-damages-democracy
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap583872700581.jpg?itok=s1dPDZqJ" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Dennis Van Tine/STAR MAX/IPx via AP</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Donald Trump at a rally at Mohegan Sun Arena in Wilkes-Barre, Pennsylvania, on October 10, 2016. </p>
</div>
</div>
</div>
</div>
</div>
<p><em>This article, written in September, appears under the title "When Elections Fail" in the Fall 2016 issue of </em>The American Prospect <em>magazine. <a href="http://www.prospect.org/subscribe">Subscribe here</a>. </em></p>
<p><span class="dropcap">O</span>ne of the great advantages of liberal democracy is the potential for self-correction. If an election works out badly, the next one offers an opportunity to make a better choice, and in the meantime constitutional guarantees keep the winners from abusing their power. But sometimes elections fail so disastrously as to threaten irremediable damage to a society’s foundations. The United States faces that risk this year.</p>
<p>Systemically damaging election failure can happen in several ways. Elections may be rigged or manipulated and, even when they haven’t been, the suspicion that they have may impair a new government’s legitimacy and create a constitutional crisis. Elections can fail when they put strongmen in power who have no respect for constitutional norms and threaten democratic institutions. They can fail when the outcome is so dispiriting that people give up on democracy and believe that only an authoritarian government can solve their problems.</p>
<p>Although democracy is often equated with elections, the two are not the same. After squelching their opponents, authoritarians often use elections to give themselves a stamp of popular legitimacy. The liberal elements of liberal democracy—independent media, freedom of association, an impartial system of justice and administration—are not just requisites for free elections; they are also indispensable to democracy as a means of limiting the damage when elections fail. The checks and balances of our Constitution that seem frustrating at times because they serve as brakes on popular sentiment also reduce the risk that a bad decision by the voters at one moment will do irreversible, systemic harm.</p>
<p>An economic collapse, defeat in war, or some other crisis may be the most likely situations to drive a nation’s voters to make a desperate choice. But while this is an anxious time in America, it is not a moment of national desperation, though it could become one. The country faces the risk of systemically damaging election failure—threats to electoral integrity and government legitimacy, constitutional norms, and trust in the democratic process—because of the Republican Party’s nomination of Donald Trump.</p>
<p>Trump has raised the specter that if he doesn’t win, he may not accept the results because the political system is “rigged” and the election may be stolen through voter fraud. The voter-fraud issue is phony—there is no evidence of significant voter impersonation. But many of Trump’s supporters echo the views they hear from their candidate and party. A Quinnipiac poll in mid-September asked, “If your candidate loses in November, would you think that the outcome was legitimate or would you think that the election was rigged?” Nearly half the Trump supporters (46 percent) think the election would be rigged, while only 11 percent of Clinton’s supporters think so.</p>
<p>Of course, the actual purpose of spreading the myth of voter fraud is to tilt the election by justifying special ID requirements and other laws and policies that reduce the African American, Latino, and youth vote. Trump has also called for his supporters to patrol voting places on Election Day, an old tactic aimed at intimidating minority voters.</p>
<p>Another kind of threat to electoral integrity is entirely new in the American experience—intervention by a foreign power aimed at supporting one candidate or sowing general distrust of the election’s outcome. Some people are incredulous that Russian hackers who work in concert with Vladimir Putin’s government could have been responsible for the breach of the Democratic National Committee’s email system and efforts to get access to state voter registration files in Arizona and Illinois. But there is a well-established pattern of Russian actions of this kind in Europe, and Trump has given Putin an interest in an American election that no Russian leader ever previously had because no major-party American presidential candidate has previously been pro-Russian.</p>
<p>The Russian interest arises not just from the admiration that Trump has repeatedly expressed for Putin, but also because Trump has cast doubt on whether as president he would defend NATO allies in eastern Europe against Russian intervention. As a businessman, Trump has also depended, as one of his sons has said, on Russian capital, and as a candidate he has had a remarkable penchant for advisers with Russian connections. That Trump openly invited Russian hacking into Clinton’s email—before saying, implausibly, that he was just being “sarcastic”—was an astonishing example of disdain for democratic norms. And he may get his wish, or something like it. As Dana Milbank of <em>The Washington Post</em> has speculated, the trove of hacked documents may provide the material, possibly doctored, for an “October Surprise” damaging to Clinton or to public confidence in the integrity of the election.</p>
<p>In praising Putin as a strong leader, Trump has shown utter indifference to the Russian leader’s use of power, professing to know nothing about the murder of Putin’s opponents and investigative journalists in Russia or to see anything wrong in Russia’s seizure of Crimea. Trump’s own actions during the campaign—inciting violence against protesters at his rallies; attacking the judge in the Trump University case; saying that as president he would use the IRS to get back at the owner of <em>The Washington Post</em>—also give no basis for believing he would restrain himself once he sat in the Oval Office.</p>
<p><span class="pullquote-right">If elections fail in most countries, it is only their problem. If an election fails in the United States in the way it may fail in 2016, it is a problem for the whole world. </span>Trump views the alliances built since World War II as a protection racket in which countries either pay up or get no defense from the United States—treaty commitments and the fate of other democracies be damned. In Iraq, he says, we should have just taken the oil—a reversion to old-fashioned imperialism that would validate hostility to the United States. He calls for the use of torture against suspected terrorists and killing their families—forget the Geneva Conventions and other legal niceties.</p>
<p>After 1945, the United States helped to build a system of alliances and international law that has kept the peace in Europe and contributed to advances in democracy and human rights around the world. America has not always upheld those values in its actions abroad. But a Trump victory would endanger what has been achieved and do systemic damage to democracy not just in America but internationally.</p>
<p> </p>
<p><strong>BUT WOULDN'T</strong> other institutions—the courts, Congress, the federal bureaucracy—prevent Trump from carrying out his ideas? In a government so prone to gridlock, some say, Trump would find himself foiled at every turn. That confidence, however, is unwarranted.</p>
<p>In international relations, to begin with, the power of the presidency is effectively unlimited. As commander in chief, the president can take the country to war. Presidents have abrogated and suspended treaties in the past; Trump could do so with little fear that the Supreme Court would direct him to comply. The nuclear arms pact with Iran is only an executive agreement; Trump could cancel it. It’s a comforting thought that the military and the CIA would defy Trump’s orders to use torture, but I wouldn’t count on it.</p>
<p>By signaling American intentions, presidential statements about foreign affairs in speeches and news conferences often constitute actions in themselves. Trump’s mere suggestion that he would not defend countries in eastern Europe would encourage Putin to test NATO’s resolve. Last April, in an interview on Fox, Trump told Chris Wallace in regard to the Japanese arming themselves with nuclear weapons, “Maybe they would in fact be better off if they defend themselves from North Korea.” He later reversed himself, but a president has only to raise doubt about America’s commitments to trigger nuclear proliferation.</p>
<p>While presidential power is not as great in other areas, it is still formidable. Under existing laws, Trump would have sufficient discretionary authority to bar immigration from predominantly Muslim countries (see Sasha Abramsky, “<a href="http://prospect.org/article/don’t-assume-trump’s-bias-mere-bluster">Don’t Assume Trump’s Bias Is Mere Bluster</a>,” <em>The American Prospect</em>, Summer 2016). Trump would also have the legal authority to carry out mass deportations of undocumented immigrants. And he could appoint an attorney general (Chris Christie?) and other officials who would be able to undertake investigations of political opponents and critical media and who might cast aside the informal norms that restrain the government’s staggering prosecutorial power and its capacity to disable the opposition.</p>
<p>Perhaps the greatest dangers to democracy and civil liberties would arise from the repercussions of Trump’s policies. Many of the actions that Trump has called for have the potential to ignite crises. Canceling the Iran pact could precipitate another crisis in that region. Anti-Muslim policies could stimulate more terrorism. Mass deportations and the cancellation of trade agreements, followed by retaliation by other countries, could create economic turmoil.</p>
<p>The turmoil itself would be an opportunity for Trump, as it often is for right-wing populists. After coming to power through appeals to intense nationalism and hostility to minorities and foreigners, they often use foreign conflicts or trouble at home as a way of maintaining support and justifying crackdowns on their domestic opponents.</p>
<p>There is also a more immediate potential for a constitutional crisis if this year’s election produces a disputed outcome. Imagine a repeat of the battle over the Florida vote in the 2000 election, except that with only eight justices, the Supreme Court might now be deadlocked. That could leave the election outcome to a lower court with even less legitimacy to determine the fate of the nation. Al Gore averted a constitutional crisis in 2000 by simply giving way, but it is hard to imagine Trump doing the same, and Clinton might not either.</p>
<p><span class="pullquote-right">If Trump becomes president, would Congress keep him in check, particularly under the pressure of crises that Trump himself might produce?</span> If Trump wins, Republicans are likely to hold both houses, and the odds are low that they will conduct the equivalent of the Watergate hearings to check abuses of presidential power. This year, we have already seen how little fight Republican leaders put up against Trump once he was the presumptive nominee, despite the contempt he had shown for many of them and for what we had long been told were the party’s true principles. His ability to intimidate others into silence and compliance would be far greater as president than it has been as a candidate.</p>
<p>Since Trump’s authoritarianism is hardly a secret, his candidacy itself reveals something deeply disturbing about the Republican Party in particular and America in general. No candidate like Trump was ever supposed to have a chance at the presidency. But for some time now, Republicans have been playing with fire, stoking hostility to government and doubts about its legitimacy. Trump is the culmination of that pattern. After years of unrelenting contempt for public institutions, democracy in America may now be much more fragile than many of us previously understood.</p>
<p>When elections fail, everything depends on democracy’s other institutions—the courts, civil service, parties, independent media, civil society—but those institutions are not self-driving vehicles. While constitutional checks and balances create brakes on elected leaders, people have to apply the brakes. In the first instance, the brakemen are the judges and others with independent power in the government and major private institutions. Not only can they refuse to go along with illegitimate decisions; they can also embolden wider public resistance. In one of his great free-speech opinions, Justice Louis Brandeis wrote that the founders of the American Republic “believed liberty to be the secret of happiness and courage to be the secret of liberty.” When democracy is going well, it is easy to forget how vital courage is. When elections fail and all seems to fall apart, nothing is more important.</p>
<p><em>—September 20, 2016</em></p>
</div></div></div>Tue, 18 Oct 2016 09:00:00 +0000225907 at http://prospect.orgPaul StarrWhat Is Hillary Clinton’s Agenda?http://prospect.org/article/what-hillary-clinton%E2%80%99s-agenda
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><em>This article appeared in the Summer </em><em>2016</em> <em>issue of </em>The American Prospect<em> magazine.</em><em> <a href="http://www.prospect.org/subscribe">Subscribe here</a>. </em></p>
<p><span class="dropcap">I</span>t is misleading, some observers have rightly pointed out, to treat the 2016 election as a contest between two candidates who are equally serious about policy. Donald Trump has been on both sides of many issues, contradicting himself from one day to the next. On occasion, he has given a speech written by advisers on a subject like energy where he seemed as surprised by the text as the audience was. He has a core of symbolically important positions on such issues as immigration, but otherwise his views are murky. Much of what he says about foreign or domestic problems is all impulse and no thought, so when his impulse momentarily changes, his positions change too.</p>
<p>For Hillary Clinton, however, substance actually does matter. Her seriousness defines her. We have not reached the stage of gender equality when a woman candidate for president could get away with being as subject to changing moods and personal pique as Trump is. While no one would know what to expect from a Trump presidency in major areas of policy, Clinton has laid out plans in virtually every domain. That plenitude of nuanced and multilayered policies is both an asset and a limitation. It is valuable in signaling to different groups where her commitments lie, and it will be an asset in governing if she is elected. But it is a limitation in a political campaign for reasons that have been especially clear this year.</p>
<p>Whether voters love or hate Trump, they can name a few big things he says he would do as president: build a wall on the Mexican border, round up and deport illegal immigrants, ban Muslims from coming to America, and redo trade deals. Similarly, Democratic primary voters this year were able to identify Bernie Sanders with a few major promises: break up the banks, make public college free, and pass what he calls “Medicare for all.”</p>
<p>Despite Clinton’s ample detail—her website covers more than 30 different issue areas, each with bullet points about specifics—voters would probably be hard-pressed to come up with three or four big ideas they identify with her. Although it is hardly a weakness of a presidential candidate to be prepared for the scope of the job, her campaign has not had a clarifying focus on a few big themes or proposals that instantly communicate what she wants to do.</p>
<p> </p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap733038268425.jpg?itok=baJ0896u" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Kathy Willens, Pool</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Clinton talks with a youngster at an early childhood education center in New York in 2015. </p>
</div>
</div>
</div>
</div>
</div>
<p>The strategy that Clinton has adopted thus far this year may be partly to blame. Seeking to rally diverse constituencies, she has framed her candidacy in broad, progressive terms, often saying she wants to break down “all the barriers” facing people—not just economic barriers, but also those based on race, gender, sexual orientation, and other sources of disadvantage. She also says she wants to build on Barack Obama’s presidency, and since Obama has previously supported much of what she favors, those ideas do not have her own stamp—at least not yet. In contrast to Sanders, she has repeatedly said she doesn’t want to make unrealistic promises, and against both Sanders and Trump, she has cast herself as the candidate of responsibility and refused to call for huge programs or huge tax cuts that would balloon the federal deficit. In another presidential year, she might get credit for good judgment; this year, she gets criticized for lacking imagination.</p>
<p>Perhaps concerned about the media seizing on whatever issue she leaves out, Clinton has resisted indicating which of her proposals would have priority. In a profile this spring in <em>New York Magazine</em>, Rebecca Traister reports Clinton saying she doesn’t accept the premise that as president she would have to choose which issues to advance first, assuming a two-year window of opportunity to move legislation through Congress. “I want to take everything I’ve said I’m going to work on and be as teed up as possible from the very beginning. I want to give [Congress] every opportunity to move forward on several fronts.”</p>
<p>Of course, advances along those fronts depend on the outcome of the congressional election. If Democrats win control of the Senate as well as the presidency, it would help Clinton with both judicial and executive nominations, but not necessarily with epochal legislation if Republicans still hold their House majority. In the less likely scenario in which Democrats also win back the House, the legislative logjam since 2011 could break open—especially if Senate Democrats eliminate the filibuster (as they did for appellate court nominations in 2013). <span class="pullquote">Even if the odds of full control of Congress are low, Clinton ought to be “teed up” to take advantage of that possibility.</span> Both Bill Clinton and Obama had a two-year window at the beginning of their presidencies, and most of the progressive legislation of recent decades was enacted during those intervals—the only four years of unified Democratic government in the past 36.</p>
<p>Before getting ahead of herself, however, Clinton has to win the election, and it is first of all for that purpose that she needs to define her priorities more sharply. Unlike Trump, she’s not going to go to extremes to make her case. But voters should know what to expect from her, and she needs to find ways to convey ideas that will stand out in their minds.</p>
<p> </p>
<h2>Focusing Clinton’s Economic Agenda</h2>
<p>The economy and jobs usually top the list of voter concerns, so let’s begin there. Although Clinton’s approach to economic issues isn’t embodied in one or two signature policies, her agenda does have a thematic unity, summed up in a phrase she often uses, “giving working families a raise.”</p>
<p>A higher minimum wage is an unambiguous expression of that theme. In the Democratic primaries, the clash between Clinton and Sanders over the size of a minimum-wage increase obscured their agreement on a big jump. Raising the federal minimum from $7.25 to $12—the level Clinton has endorsed—would be the single largest increase in the history of the minimum wage in either percentage or absolute terms. (She also supports efforts in states and municipalities to raise their minimum wages to $15.) Clinton should be able to draw a sharp contrast on the issue with Trump, who has said that wages in America are “too high,” though in his customary style, he has also casually suggested he could support a minimum-wage increase, as if a Republican Congress would send him one.</p>
<p>Several other elements fit into Clinton’s overall theme, each of which articulates to other elements in her campaign. Like Obama, who increased infrastructure spending as part of the economic-recovery program soon after taking office, Clinton says that during her first 100 days she will call upon Congress to boost investment in roads, bridges, and other public works more than at any time since the development of the interstate highway system in the 1950s. Closely related are policies to increase investment in clean energy, including measures aimed at installing half a billion solar panels and generating enough power from alternative sources to run all of America’s homes in four years. In line with the effort to give working families a raise, she’s pledged not to increase taxes for those making less than $250,000 a year, proposing instead to finance investments in infrastructure and other measures by closing “corporate tax loopholes” and making “the most fortunate pay their fair share.”</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap16109518108634.jpg?itok=k9zWXDYp" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Pablo Martinez Monsivais</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>If Democrats win big in November, the outcome may be seen, above all, as a mandate on immigration reform. Here, supporters of fair immigration reform gather in front of the Supreme Court in Washington, Monday, April 18, 2016. </p>
</div>
</div>
</div>
</div>
</div>
<p>Here it is worth taking a moment to consider Clinton’s revenue and tax-fairness proposals in light of what Obama has done. Although you might never know it from discussion among progressives, the Obama years have seen a major shift in tax burdens from lower- and middle-income people to the rich. In 2009, Congress enacted three tax-credit increases that were later made permanent (the Earned Income Tax Credit, the Child Tax Credit, and the American Opportunity Tax Credit). Together, these have cut taxes for 24 million working- and middle-class families by an average of about $1,000. The subsidies for health-insurance premiums in the Affordable Care Act (ACA) represent another substantial benefit for those with low to middle incomes. At the median income, the federal income tax rate is now 5.3 percent, which is lower than the average in any presidential administration since the 1950s, indeed, less than half the rate during Jimmy Carter’s presidency (1977–1980).</p>
<p>The flip side of the Obama record on taxes has been higher taxation of upper-income households. In 2010, congressional Democrats and the president prevented the extension of the tax cuts for the rich enacted under George W. Bush, increasing the top marginal income tax rate back to its level during the Clinton administration (39.6 percent) and reducing tax cuts on investment income and estates. When these changes went into effect in 2013, the top 0.1 percent paid $50 billion in taxes more than they would have paid under the previous rules. Partly as a result of a provision in the ACA, the tax rate on capital gains has gone from 15 percent to 23.8 percent.</p>
<p>Clinton’s proposals move in the same progressive direction, raising taxes on top incomes and providing relief to the less affluent. To pay for her new initiatives, she is calling for a 4 percent surtax on people with incomes over $5 million and a new minimum tax of 30 percent on those with pre-deduction incomes of more than $1 million. Several of her tax proposals are aimed at promoting long-term investment within the United States. These include increases in capital gains taxes for assets held for less than six years and other changes in tax policy to discourage high-frequency trading and shifts of corporations, jobs, and investment abroad. One little-discussed idea she has endorsed is a tax credit to encourage corporations to adopt employee profit-sharing plans. According to an analysis by the nonpartisan Tax Policy Center, Clinton’s tax proposals would generate about $1.1 trillion over a decade: “Nearly all of the tax increases would fall on the top 1 percent; the bottom 95 percent of taxpayers would see little or no change in their taxes.”</p>
<p><span class="pullquote">Besides paying for infrastructure investments, much of the tax revenue Clinton proposes to raise would go to purposes that bear out her theme of “giving working families a raise.” </span>Clinton would use some of the revenue to finance her proposal for paid family leave. In the same vein, she is proposing to move toward universal pre-K by providing new funds to states that expand access to preschool for all four-year-olds. She has also discussed limiting families’ child-care costs to 10 percent of income, and although she hasn’t yet spelled out the details, that idea could involve refundable tax credits. The proposals add up to a clear message, if Clinton and the Democrats can communicate it: tax fairness on behalf of families who are struggling to make ends meet.</p>
<p>On taxes, the contrast with Trump could hardly be more dramatic. Trump’s tax plan calls for sharp cuts in federal income tax rates, including a reduction in the top rate from 39.6 percent to 25 percent. According to the Tax Policy Center, the top 1 percent would see their taxes fall on average by more than $275,000, while the top 0.1 percent would enjoy a windfall averaging over $1.3 million. For the lowest-income households, the tax cut would amount to $128; for middle-income households, $2,700. In addition, Trump would also completely eliminate federal estate taxes—which currently apply only to estates worth more than $5.45 million—and reduce taxes on business. The total loss in federal revenue, conservatively estimated by the Tax Policy Center at $9.5 trillion over ten years, would lead to severe cuts in federal programs or massive increases in deficits, or both. (The estimate of lost revenue is conservative because it doesn’t take into account rising interest costs from rising deficits.) Trump has ruled out cuts in Social Security and Medicare. On that assumption, other federal spending—defense, transportation, health, education, and so on—would have to be cut by about 80 percent to balance the budget. Since cuts of that magnitude aren’t feasible, the deficit would likely grow explosively.</p>
<p>In the contest over economic policy, Trump benefits from the undeserved impression that he has been a business genius and, more generally, from gendered expectations about the two candidates. In contrast to Clinton’s family-centered economics, Trump offers a seemingly more muscular, nationalist alternative. He promises to get factories humming by slapping tariffs on foreign imports, undoing environmental and other regulations, and boosting production of fossil fuels, including coal. Deporting the 11 million unauthorized immigrants fits with the same approach. It’s a turn-back-the-clock agenda that may appeal especially to white, industrial workers who have lost ground in recent decades, even though the job losses in manufacturing over the past half-century primarily stem from long-term technological change that, especially with advances in robotics, will almost certainly continue regardless of Trump’s policies. Rather than helping workers, Trump’s threatened tariffs could set off a trade war that would cost jobs in export-oriented industries, and the mass deportations he calls for would be not only inhumane but also economically devastating to the regions in the United States where immigrants account for much of the workforce and consumer demand.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap906153358576.jpg?itok=AQoEZl9W" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Danny Johnston</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Hillary Clinton and her daughter Chelsea Clinton speak at a "No Ceilings" event dealing with women's issues at the Clinton Presidential Center in Little Rock, Arkansas, November 15, 2014. </p>
</div>
</div>
</div>
</div>
</div>
<p>Clinton isn’t conceding ground to Trump on industrial jobs. She is proposing to devote $10 billion to regional alliances called “Make it in America Partnerships,” aimed at strengthening industrial competitiveness and building on the National Network for Manufacturing Innovation established under legislation that Ohio Senator Sherrod Brown sponsored in 2014. The clean-energy proposals also aim at fostering manufacturing jobs. Acknowledging that trade has had mixed effects on manufacturing, she says new trade agreements have to meet “a high bar” and has backed away from supporting the Trans-Pacific Partnership.</p>
<p>But whereas Trump wants to wall America off from outsiders and revert to an unrecoverable past, Clinton’s agenda is fundamentally modernizing. She calls for more investment in science and technology, urges increased assistance to students to make college debt-free, accepts the facts of climate change, and generally favors trade and openness to the world. As against Trump’s “America First” foreign policy, she is committed to upholding America’s international agreements and leadership role on a planet that has become more interconnected than ever. Her support for paid family leave, universal pre-K, and assistance with child-care costs reflects a commitment to bring national policy in line with the contemporary realities of family life.</p>
<p>Clinton properly frames those family-centered economic policies as a foundation of general prosperity. “The movement of women into the American workforce over the past 40 years was responsible for more than $3.5 trillion in economic growth,” she argued in a speech last July. But whereas “the United States used to rank seventh out of 24 advanced countries in women’s labor force participation,” America dropped to 19th by 2013, partly because other countries are “expanding family-friendly policies like paid leave and we are not.” High-quality, affordable child care, she said, “is not a luxury. It’s a growth strategy.”</p>
<p><span class="pullquote">Clinton’s challenge is to persuade voters that her vision of what she calls a “growth and fairness economy” is rooted in today’s America, and Trump’s is stuck in yesterday’s.</span> “When he says, ‘Let’s make America great again,’” Clinton declared on June 7, “that is code for ‘Let’s take America backward.’” She needs to press the case that Trump has lied about who would benefit from his tax plan and that the tough-guy image is fake—he has no practical way of making American industry great again, either by muscling other countries in trade or by deporting millions of immigrants. But while framing Trump’s notions as backward-looking bombast, Clinton also has to fill in what are still blanks in many voters’ minds about her own program, spelling out how she would “give working families a raise.” A historic increase in the minimum wage, a big infrastructure program, tax fairness, and new policies centered on families and children can provide the substance behind that theme.</p>
<p> </p>
<h2>A Referendum on America</h2>
<p>The priorities that emerge from an election and shape a presidency often depend on the conflicts that the election itself highlights, based on the identities and personalities of the candidates as well as the issues they campaign on. The 2016 election has become a referendum on the kind of society that the American people want. Eight years ago, Barack Obama’s candidacy put to the test how far Americans had come in accepting African Americans as full and equal citizens. This year’s election is also about diversity, but the conflict now focuses on immigrants because of Trump and on women because of Clinton—and Clinton has every reason, and shows every sign, of using the stark challenge that Trump poses as a call to arms to voters and, if she wins, a mandate for action.</p>
<p>By nominating Trump, Republicans have raised the stakes on immigration. Under George W. Bush and again in the wake of the 2012 election, Democrats thought they could reach agreement with Republicans on legislation to provide a path to citizenship for long-settled, law-abiding unauthorized immigrants. That era appears to be gone now that the GOP has a nominee threatening mass deportations. If Democrats win big in November, I expect the outcome will be seen, above all, as providing a mandate on immigration reform. A decisive rejection of Trump will be a vote for an open, diverse society, and both Clinton and congressional Democrats will be emboldened to confirm that choice. But if Democrats fall short and immigration reform fails again, Clinton has committed to maintaining and expanding the administrative actions that Obama has taken in protecting Dreamers and others among the undocumented (actions, however, that are pending before the Supreme Court).</p>
<p><span class="pullquote">Immigration reform—together with racial-justice issues—will likely receive priority for another reason: the political debt that Democrats, and Clinton in particular, owe to the black, Latino, and Asian American communities.</span> Clinton would not be the presumptive Democratic nominee if she hadn’t won overwhelming majorities among minority voters in the primaries. One of the first speeches she gave in the campaign was about ending the era of mass incarceration; she was also early to focus on the drinking-water crisis in Flint, Michigan, as an issue of environmental justice. She cannot afford to forget those commitments. Four years from now, minority voters could again be crucial to her re-election.</p>
<p>Gender-related concerns were bound to arise in the first presidential election with a woman at the head of a major-party ticket. But Trump’s sexist comments about women, open talk about the size of his penis, and peacock-like demeanor have put the politics of gender into the spotlight in an unprecedented way. Clinton couldn’t have picked a better foil for making her case for women’s rights and a vision of prosperity with families and children at the center. Just as with immigration, Clinton will have the basis for claiming a mandate on those issues if she wins in November.</p>
<p> </p>
<p><strong>IF THE REPUBLICAN PARTY</strong> hadn’t turned as far right as it has in recent years, there might well have been possibilities for bipartisan cooperation on other major issues besides immigration. Two of these, climate change and health care, have now become long-term reform projects identified with the Democratic Party, begun in earnest under Obama and necessarily of high priority to a Democratic successor.</p>
<p>Trump again makes the stakes exceptionally clear. While some Republicans at least acknowledge global warming, Trump once tweeted that the very idea is a Chinese conspiracy to dismantle American manufacturing. In May, as part of his energy speech, which could have been summed up as “fossil fuels forever,” he pledged to “cancel the Paris climate agreement” and rescind environmental regulations that cut carbon emissions.</p>
<p>Picking up where Obama leaves off, Clinton has primarily focused on using authority under existing law to promote clean energy and reduce carbon pollution. The failure of Senate Democrats in 2010 to pass a cap-and-trade program approved by the House showed how difficult it is for Democrats, even with a Senate majority, to get representatives from coal-dependent states to vote for any bill moving the country toward energy alternatives. Besides defending Obama’s executive actions—in particular, the Clean Power Plan, which effectively bars new coal-fired power plants—Clinton is calling for higher fuel-efficiency standards, changes in leasing practices on federal lands, and stricter regulation of methane emissions (and therefore of fracking). Democratic control of Congress would be necessary for some measures Clinton is supporting, such as new investments in clean-energy infrastructure and an end to tax subsidies to the oil and gas industries.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap9309280106.jpg?itok=w9LwQReA" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Doug Mills</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Clinton testifies on health-care reform in 1993. Improving the ACA would be a top priority now. </p>
</div>
</div>
</div>
</div>
</div>
<p>On health care, there was some confusion last fall about where Trump stood. While calling for the repeal of Obamacare, he suggested that he might deviate from Republican orthodoxy and propose a program for universal coverage. But by February he backtracked, issuing a plan that would not only end coverage for about 20 million people who have gained it through the ACA but also effectively nullify state regulation of health insurance. The plan would allow insurance to be sold across state lines, enabling insurers to locate in states with the weakest laws.</p>
<p>Health-care reform has been the national issue most closely identified with Clinton, dating back to her role as the public advocate for her husband’s plan in 1993. She has a grasp of health policy few other public figures can match, and while continuing to carry out the ACA, she may now also have the opportunity to fix problems with the law, especially if Democrats secure a congressional majority.</p>
<p>In their early going, major reforms often need reforming themselves. After enacting Social Security in 1935, Democrats controlled both Congress and the presidency for more than a decade, which enabled them to amend and consolidate the program. Likewise, after passing Medicare and Medicaid in 1965, they were also able soon afterward to adjust those programs in amendments. But immediately after passing the ACA, Democrats lost control of Congress, and although Republicans have been unable to repeal the law, they have blocked constructive changes. The ACA, many Democrats initially said, would be a foundation they could build on, but they haven’t had the chance due to the gridlock in Washington.</p>
<p>Several problems now stand out as legitimate sources of dissatisfaction with health-care reform: high levels of patient cost-sharing in plans available in the insurance marketplaces; continued difficulties among low-income families in affording premiums; narrow networks (that is, lack of choice of physicians and other providers); and lack of competition among insurers in some states and regions. To help make coverage more affordable, Clinton is proposing a tax credit of up to $5,000 per family to offset a portion of the out-of-pocket and premium costs that exceed 5 percent of family income—another example of giving working families a raise. She would require insurers to limit out-of-pocket prescription drug costs to $250 per month for patients with chronic or serious conditions. She wants to increase incentives for states to expand Medicaid. And, as she did in her 2008 presidential campaign, she is supporting the establishment of a “public option” as a competitive alternative to private plans in the insurance marketplaces.</p>
<p>A public option could come in different forms. One possibility endorsed by Clinton is a Medicare buy-in for people when they reach age 50 or 55. This is not a new idea; Bill Clinton proposed it for 55- to 64-year-olds in the late 1990s and Al Gore supported it in his 2000 presidential campaign. The difficulty then was the likely cost resulting from “adverse selection”; the people most likely to enroll would have been those in poor health with high medical costs. Although this problem won’t have disappeared, it should be more manageable because of the subsidized plans already available in the insurance marketplaces. In fact, by taking 50- or 55- to 64-year-olds out of the general risk pool, a Medicare buy-in could result in lower premiums (and therefore lower federal tax subsidies) for everyone else in the insurance marketplaces. Letting Medicare compete for middle-aged enrollees in the insurance exchanges could be an incremental step toward a general public option. Short of congressional action on the Medicare buy-in or a general public option at the national level, Clinton has said she will use the flexibility already provided by the ACA to help states establish their own public options. <span class="pullquote">Considering Clinton’s long personal involvement in health-care reform, the issue should be a top priority of hers.</span></p>
<p> </p>
<p><strong>TO THE SHORT LIST OF REFORM </strong>projects that will likely rank high on Clinton’s agenda, we can add one more—democracy itself. Recent decisions by the Supreme Court and policies adopted by Republicans at the state level have increased the political importance of voting and campaign-finance rules. Whereas Republican-controlled state governments have sought to make voting more difficult, Clinton wants to make it easier. She favors automatic voter registration for 18-year-olds and a new national standard for early voting (allowing voting to begin 20 days or more before an election). She’s endorsed a small-donor matching program as part of campaign-finance reform and wants to reverse the Supreme Court’s weakening of a key provision of the Voting Rights Act, as well as the Court’s <em>Citizens United</em> decision.</p>
<p>Although Clinton would not be able to bring about many of these changes on her own authority without a Democratic Congress, she could have an enormous influence on the democracy agenda through Supreme Court and other judicial appointments. Assuming the Senate does not confirm Judge Merrick Garland during the lame-duck session after the election, Clinton—or for that matter Trump—could make as many as four Supreme Court appointments. Those choices could be the most important decisions the next president makes.</p>
<p>Ultimately, many people who cast their ballots for Clinton may vote more against Trump than for her, in part because they know enough about Trump to fear him, although they may be less clear about what Clinton would do. But Clinton has the basis for a stronger, positive case. She wouldn’t just make political history by becoming America’s first woman president; her family-centered economics provides the substance to make her presidency a milestone in American social life. After the long rise of inequality, it would not be a little thing to increase the minimum wage by 65 percent or to enact paid family leave and support for child care and universal pre-K. Affirming America’s commitment to an open and diverse society through immigration reform would also be a big deal. So would pushing ahead on the great energy transition and universal health care, as well as a revitalized democracy. The battle during the primaries left some Democrats feeling that Clinton wasn’t reaching high enough. But if she can accomplish half of her agenda, they may feel very different.</p>
</div></div></div>Mon, 20 Jun 2016 09:00:00 +0000225128 at http://prospect.orgPaul StarrTrump’s Nomination Will Shake Confidence in American Democracyhttp://prospect.org/article/trump%E2%80%99s-nomination-will-shake-confidence-american-democracy
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_479655658890.jpg?itok=Ec-yLUrS" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(Photo: Sipa USA via AP/Monica Jorge)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Protesters gather in Hartford, Connecticut, during a rally for GOP presidential candidate Donald J. Trump on April 15.</p>
</div>
</div>
</div>
</div>
</div>
<p><span class="dropcap">W</span>ith his victory in Indiana yesterday, Donald Trump is now, as he claims, the “presumptive” Republican presidential nominee. Although the polls indicate he’ll likely lose to Hillary Clinton, the election is half a year away, and a lot can happen in between. The consequences of Trump’s becoming president would be momentous for both America and the world. It would change forever the way we think about democracy—and the way the world thinks about America. In fact, his nomination alone will have a deep impact even if he ultimately loses.</p>
<p>A major-party nomination legitimizes a candidate’s views as worthy of fair consideration. As a “birther” doubting Barack Obama’s citizenship, Trump could be treated as a crank. In the early stages of the primary campaign, his statements about Mexicans and Muslims could be regarded as the wild fulminations of a candidate who would surely be rejected by his party in the end. When his followers attacked protesters at his rallies and Trump himself encouraged and defended their attacks, many people expected that the public would recoil from his thuggishness. <span class="pullquote-right">This was not America—at least, so we thought.</span></p>
<p>But with the nomination in hand, Trump will have the nation’s full and even respectful attention for whatever provocations he finds it useful to make. The charge he made this week that Ted Cruz’s father was involved in the assassination of John F. Kennedy will not be the last of his reckless accusations. Since a brazen indifference to the truth has worked out well for Trump, we can only expect more of it. The ugliness and degradation he has brought to the Republican primaries he stands ready and able to bring to the general election.</p>
<p>Democracy was already in poor health before this election. Republican obstruction has made it impossible to attend to many of the country’s deep and persistent problems; Congress has repeatedly ground to a halt and been unable to act on pressing issues. Special-interest money and influence have intensified cynicism about politics and undermined trust not only in national leaders but also in national institutions. Trump has taken advantage of the resulting disgust with the “system” even though he has been one of the people buying influence, as he proudly acknowledges.</p>
<p>It is fair to say, as many have, that the Republican Party establishment has brought Trump on itself by inflaming the passions of its conservative base, playing to white nationalism, and blocking constructive action on such issues as immigration. <span class="pullquote-right">But the GOP has done more than bring Trump down on itself; it has given him legitimacy and put him in reach of the nation’s highest office.</span></p>
<p>The United States has been remarkably fortunate throughout its history. Democracy is not an unerring method for choosing wise leadership, and certainly not all of our leaders have been wise. But the United States has never had a strongman in the Latin American style. We have not had a thug who put constitutional government at risk.</p>
<p>For a century, the democratic countries of the world have been able to count on America’s stable leadership. Trump’s nomination will shake the confidence that they can continue to count on us. It will also shake the confidence in democracy of many Americans, both Republicans and Democrats, who abhor both the substance and style of his politics. As the election of a black president in 2008 renewed faith in American politics, so Trump’s nomination will lead many to doubt whether they can depend on the choices of their fellow citizens. This may turn out to be of the biggest costs of Trump’s rise to respectability and the GOP’s descent into darkness. </p>
</div></div></div>Wed, 04 May 2016 13:00:06 +0000224809 at http://prospect.orgPaul StarrThe Strange Silence about Sanders’s Tax Proposalshttp://prospect.org/article/strange-silence-about-sanders%E2%80%99s-tax-proposals
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><span class="dropcap">O</span>ne of the regular patterns in public opinion polling is that approval for proposed programs is higher if a survey question omits any reference to the cost in higher taxes. The same phenomenon has probably also been at work in the Democratic primary race this year. Bernie Sanders has been calling for the federal government to pay for free health care, free college tuition, and other programs, but neither Hillary Clinton nor the media have focused much attention on the tax implications. </p>
<p>If Sanders were to become the Democratic presidential candidate, the silence surrounding the tax issue would surely end. Republicans may be holding fire on Sanders’s proposed taxes in the confident expectation that they could use them against his candidacy in the general election. That’s all the more reason Democrats themselves should want to get the issue out on the table now.</p>
<p>The gulf separating the tax proposals of presidential candidates this year—between Republicans and Democrats, and between the two Democrats—is an example of how radically polarized much of American politics has become. On one side, the Republicans are proposing staggering tax cuts: Ted Cruz would cut federal revenues over the next decade by $8.6 trillion, Donald Trump by $9.5 trillion. On the other side, Sanders’s proposed tax increases are even larger than the Republican tax cuts—$15.3 trillion. The distributive effects go in opposite directions: While the rich get the biggest benefit of the Republican cuts, they bear the biggest burden of Sanders’s increases.</p>
<p>Like Sanders, Hillary Clinton also proposes to increase taxes on the rich, and in any other recent election, her proposals would have been seen as distinctly progressive. She calls for a new surtax of 4 percent on those with incomes over $5 million, a new minimum tax of 30 percent (the “Buffett rule”) on those with pre-deduction incomes of over $1 million, increases in capital gains taxes for assets held less than six years, a new tax incentive for employee profit-sharing, and other changes in tax policy to discourage high-frequency trading and shifts of corporations, jobs, and investment abroad.</p>
<p>But while the direction of tax changes proposed by Clinton and Sanders is similar (and some specific provisions overlap), there is a huge difference in magnitude. Clinton’s proposed tax increases amount to $1.1 trillion over a decade, an amount that seems comparatively modest since Sanders’s tax increases exceed hers by a ratio of 14 to 1.</p>
<p>Sanders and his supporters reject analyses that emphasize the tax side of his proposals alone on the grounds that the funded government programs will relieve Americans of other costs, notably private health insurance premiums and out-of-pocket health expenses. The force of that argument depends, however, on the true cost of Sanders’s single-payer health plan. According to his campaign, the plan would require raising $1.38 trillion annually in additional federal revenue, nearly as much as the federal income and estate taxes raise today. But other analysts calculate that even that amount would be insufficient. Kenneth Thorpe, an economist at Emory University, puts the cost (over current federal spending) at $2.43 trillion annually (“<a href="http://prospect.org/article/why-sanders%E2%80%99s-single-payer-plan-would-cost-more-his-campaign-says">Why Sanders’s Single-Payer Plan Would Cost More Than His Campaign Says</a>”). Once the added taxes needed to pay for the plan are factored in, it would no longer produce the net savings Sanders is promising to the majority of the currently insured.</p>
<p>The most reliable, independent analysis of the candidates’ tax proposals comes from the Tax Policy Center (TPC), a joint effort by economists at the Urban Institute and the Brookings Institution who are widely respected for their professionalism. This is the source of the projected revenue effects for the Trump, Cruz, Clinton, and Sanders proposals I have already cited. (The TPC projections are “static” estimates that assume no behavioral change in response to the taxes but provide a reasonable baseline for comparisons.) Unless otherwise noted, I use the TPC numbers.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap308041619976.jpg?itok=vZPltNyT" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Bill Clark/CQ Roll Call/AP Images</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Senate Budget ranking member Bernie Sanders holds a news conference to introduce legislation "to make millionaires and billionaires pay their fair share of estate taxes and close loopholes that have allowed billionaires to avoid billions in taxes" on Thursday, June 25, 2015. </p>
</div>
</div>
</div>
</div>
</div>
<p>For journalistic analysis of the tax issues in the Democratic campaign, the best source has been Vox. The major newspaper, broadcast, and other media have given the issue surprisingly little attention. Part of the explanation for that inattention may be that Clinton has chosen not to attack Sanders on taxes, perhaps out of fear of alienating his supporters, whom she hopes to win over for the general election. Some journalists may also believe that Sanders’s proposals are so unlikely to be adopted that there is no point reporting on them. Others in the media may have avoided the tax issue because of the sheer complexity of what Sanders is proposing. If he was calling for just one tax increase, that might have become a focus of discussion. But he is proposing so many different increases for so many different programs that the subject is dauntingly complex. </p>
<h3><strong>The Sanders Tax Proposals</strong></h3>
<p>The TPC report on Sanders’s tax proposals distinguishes more than 30 proposed changes, nearly all of them raising taxes. In an earlier article, I grouped many of these changes together and referred to Sanders as having proposed 11 different tax increases. I was counting six of these as coming from his single-payer health plan (as the Sanders campaign itself presents them):</p>
<p>1) a new payroll tax of 6.2 percent;</p>
<p>2) an additional, across-the-board 2.2 percent tax on income;</p>
<p>3) higher estate taxes;</p>
<p>4) taxing capital gains and interest as ordinary income for individuals with incomes over $200,000 (and for married couples with income over $250,000);</p>
<p>5) limiting tax deductions for those upper-income taxpayers; and</p>
<p>6) higher income-tax rates in the form of new surtaxes on the same group.</p>
<p>Then there are five other tax increases linked to different programs:</p>
<p>7) an additional increase in payroll taxes of 0.2 percent for paid family leave;</p>
<p>8) lifting the income cap on Social Security taxes to pay for higher Social Security benefits; </p>
<p>9) a financial transaction tax to pay for free public college tuition and student debt relief;</p>
<p>10) a tax on carbon fuels, which would fund alternative energy projects and rebates to Americans making less than $100,000 a year; and</p>
<p>11) a package of increases in corporate taxes to finance new infrastructure investment.</p>
<p>Although these tax increases are heavily oriented toward the top brackets, they are not insignificant for middle-income households. Middle- and lower-income people would be mainly affected by the 6.4 percent rise in payroll taxes and the across-the-board, 2.2 percent income-tax rise—increases that together account for about two-fifths of the additional revenue Sanders raises. In the short run, some employers may bear the cost of additional payroll taxes, but economists generally agree the long-term impact falls on employees even if the employer nominally pays the tax. On that assumption, households with incomes in the middle fifth of the income distribution would see their taxes rise by nearly $4,700, or 8.5 percent of their average after-tax income.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap287774433219.jpg?itok=QO_mh4eX" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/J. David Ake, File</div>
</div>
</div>
</div>
</div>
<p>As a result of the new surtaxes on income and other measures, upper-income households would pay a lot more. The top fifth would see their taxes increase by an average of about $45,000 (17 percent of their after-tax income), while those in the highest bracket, the top .1 percent, would pay $3.1 million more in taxes (45 percent of their average after-tax income).</p>
<p>Taking both payroll and income taxes into account, marginal tax rates—the tax on the next dollar earned—would go up for middle- and upper-income households, but a lot more for those with high incomes. For example, individuals making between $78,300 and $118,500 would see their marginal rate rise from 37.4 percent to 43 percent. Marginal rates for those with incomes between $500,000 and $2 million would go from 42.8 percent to 59.4 percent, and the rates in Sanders’s top bracket (more than $10 million) would hit 67.3 percent. These marginal rates on top incomes would be as high as Sweden’s (67 percent), somewhat higher than Denmark’s (55.6 percent), and much higher than the top marginal rates in Germany and the United Kingdom (both 45 percent).</p>
<p>While raising tax rates on upper-income taxpayers, Sanders also holds down the value of deductions for them. Here’s how he does it: For individuals with up to $200,000 income, Sanders retains the current income tax brackets up to the 28 percent level. The surtaxes on higher incomes—ranging from an additional 9 percent on income between $200,000 and $500,000 to an additional 24 percent on income over $10 million—fall on income <em>before</em> deductions (“adjusted gross income”). As a result, individuals with incomes above $200,000 get only 28 percent of the value of a deduction, even though they are in higher tax brackets. Clinton also caps deductions for the rich, except that her cap does not apply to charitable donations—a difference of some importance to the nonprofit sector.</p>
<p><span class="pullquote">Putting together his different proposals, Sanders would raise the top capital gains tax rate to 64.2 percent. </span>That would be the highest of any developed country by a wide margin—more even than the two Scandinavian countries Sanders often mentions as models. Denmark, which has the highest rates in Europe, has a 42 percent rate; Sweden, 30 percent. In the United States, the federal rate on capital gains has risen under Barack Obama from 15 percent to 23.8 percent. Sanders’s proposed 64.2 percent rate on capital gains does not include his new financial transaction tax, which would be levied on the total value of transactions, not the net gain. Counting state capital gains taxes averaging about 4 percent, the total top marginal rate in the United States would approach 70 percent.</p>
<p>The major European countries, including those with the most progressive welfare-state policies, have generally avoided raising taxes on capital to such high levels out of concern about the consequences for investment and growth. To finance their social programs, they have instead relied heavily on value-added taxes, which fall on consumption. Sanders has been oblivious to the prudential concerns that have led socialist as well as other parties in the economically advanced democracies to limit their taxation of capital. A broad-based consumption tax like a VAT would require more direct sacrifice from the public at large. But taxes focused on the rich, corporations, and finance seem to promise no sacrifice at all from the electorate.</p>
<h3><strong>Why Democrats Should Be Concerned</strong></h3>
<p>Considered one at a time, many of Sanders’s tax proposals have genuine merit. A carbon tax would promote alternative energy, a financial transaction tax would penalize high-frequency trading, and more progressive income and estate taxes would help counteract the trend toward rising economic inequality. If we need more funds for public purposes—and I believe we do—taxes on carbon fuels and financial transactions and more progressive income and estate taxes are legitimate ways to raise that revenue.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap478474030345.jpg?itok=zhzaz94I" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Jim Mone</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>More than 3,000 supporters listen as Democratic presidential candidate, Senator Bernie Sanders addresses the crowd Saturday, April 2, 2016, a a campaign rally at the University of Wisconsin-Eau Claire. </p>
</div>
</div>
</div>
</div>
</div>
<p>But it is not possible to evaluate all the tax increases Sanders has proposed in isolation from one another and without considering their magnitude, likely economic and political effects, and public needs that his proposals leave unaddressed. Adopting these increases in taxation together, at the levels Sanders is talking about, and for the purposes he proposes to use them would be not only politically impossible but also unwise and dangerous.</p>
<p>The magnitude of the changes ought to raise both political and economic concerns. Americans have limited tax tolerance. The introduction of major new forms of taxation is a rare event in American history. When new federal taxes have been adopted—such as the income tax in 1913, the estate tax in 1916, and the payroll tax in 1935—the initial rates have been extremely low. The income and estate taxes also originally applied to a very small fraction of the population; they became forms of mass taxation only as a result of the two world wars. The payroll tax began at 1 percent on both employer and employee and was raised in small increments, typically less than half a percent at a time. There is no peacetime precedent in American history for anything like the package of tax increases Sanders has proposed: a 6.4 percent increase in payroll taxes, a dramatic increase in income taxes on top earners, increases in corporate taxes, and two entirely new taxes on carbon fuels and financial transactions.</p>
<p>If Sanders’s whole program of new taxes and expenditures were put before the Senate today, I doubt there would be a single vote for it besides that of the Vermont senator himself. If he were elected president, Democrats in Congress would beg him to back off these proposals before their certain rejection. Hypothetically, however, let us imagine the legislation passed, and the United States increased these taxes to Sanders’s proposed levels. The political dangers would be even greater as a result of the likely backlash.</p>
<p><span class="pullquote">Major increases in taxation have taken place during major wars for a good reason.</span> Wartime emergency not only creates the political basis for raising taxes in a big way; it also fosters the popular, patriotic support for complying with them. A massive tax increase without that foundation stands the risk of provoking massive resistance.</p>
<p>Our tax system depends on voluntary compliance. The Internal Revenue Service ought to be better funded and to conduct more audits. But even when it has been relatively well funded, tax collections have rested on a “tax-paying culture.” This is not something to take for granted; many other countries without that kind of culture see their taxes flouted with impunity, their governments unreliably financed, and both the rule of law and the fabric of social trust weakened as a result.</p>
<p>Earlier I noted that the TPC provides only static estimates of the revenue from the changes in tax policy that Sanders and other candidates have proposed. Dynamic estimates take into account behavioral changes and are always ideologically contentious. Conservative economists such as those at the Tax Foundation project ill effects from more taxing and spending, while left-of-center economists tend to estimate more benefit than cost. But when the proposed changes are far outside any recent historical experience, there is the additional problem that relevant data are unavailable.</p>
<div class="right-margin">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap902646607142.jpg?itok=UoVFzkEN" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/John Locher</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Supporters cheer as Democratic presidential candidate, Senator Bernie Sanders speaks at a rally Monday, March 21, 2016, in Salt Lake City. </p>
</div>
</div>
</div>
</div>
</div>
<p>This is one source of the difficulty with estimates of “optimal” taxation based on historical data. The United States did have high progressive tax rates on income during World War II and the Cold War, but compliance with the rates in that era may not be a reliable basis for estimating compliance now. The federal government in the mid-20th century enjoyed a degree of trust and confidence it no longer has; federal expenditures were heavily oriented to defense. Tax evasion today does not carry the stigma of disloyalty and lack of patriotism. Global markets and the emergence of currencies like Bitcoin and Ethereum also provide new avenues for hidden transactions. Taxes certainly can be increased on people with top incomes. Using historical data, Thomas Piketty, Emmanuel Saez, and Stephanie Stantcheva argue the top marginal rates could be raised to levels even higher than Sanders proposes. But, under the new economic and political conditions that exist today, both tax avoidance and tax evasion could limit the revenue that high marginal rates raise in practice.</p>
<p>Two of Sanders’s proposed tax changes—the increases in capital gains taxes and the financial transaction tax—are very likely at counterproductive levels. The Congressional Budget Office estimates that the revenue-maximizing level for capital-gains taxes to be around 32 percent. The CBO estimate may be too low, but at 64.2 percent Sanders’s proposed rate seems likely to backfire. Faced with such high taxes, people with appreciated assets have strong incentives to hold onto them rather than sell them, reducing the revenue the tax generates. The danger here is also a “lock in” effect—capital gets locked into current uses, limiting new investment and potentially damaging innovation and economic growth.</p>
<p>Sanders’s financial transaction tax—from which he expects to raise $75 billion annually to pay for free public college tuition and relief of student debt—raises a similar problem. It is not clear that the tax can be set at a rate that would generate $75 billion. The higher the tax rate, the more likely investors are to shift transactions to foreign markets or to change the form of assets and transactions to escape the tax. According to a TPC analysis of a financial transaction tax similar but not identical to Sanders’s, the revenue-maximizing rate on stock transactions would be .34 percent and little revenue would be lost at .10 percent; Sanders’s proposed rate is .50 percent. The TPC report adds that “an FTT at the rates being proposed by Senator Sanders would discourage all trading, not just speculation and rent seeking. An FTT appears as likely to increase market volatility as to curb it, as it would create new distortions among asset classes and across industries.”</p>
<p>If the taxes Sanders proposes don’t generate as much revenue as the programs require, he would need other taxes—or debt—to make up the difference. And that may well happen anyway because of the real cost of the programs, particularly for health care.</p>
<h3><strong>Paying for Single-Payer Health Care</strong></h3>
<p>The idea that a single-payer health plan could reduce net costs to consumers despite a tax increase has an intuitive appeal. Sanders points to other countries with national insurance programs that have lower costs than the United States. If only the United States adopted a single-payer system, the argument goes, Americans would save more in insurance premiums and out-of-pocket costs than they would pay in new taxes. Insurance companies are so little loved that doing away with them would hardly be a matter of deep popular regret.</p>
<p>I don’t doubt that nationalizing the insurance industry and adopting a uniform federal system could reduce administrative costs significantly and provide the government with the monopoly power to reduce prices for drugs and other health-care goods and services. At the same time, however, the Sanders health plan increases health costs in other ways, depends on economically and politically implausible developments, and provides no incentive for providers, patients, employers, or state governments to control costs. It would also confront intense resistance from Americans with employer-provided private insurance, the majority of whom would see themselves as losing out under the plan.</p>
<p><span class="pullquote">Although Sanders refers to his plan as “Medicare for All,” it is far more generous than Medicare. </span>It covers every sort of health care—inpatient, outpatient, long-term care, home care, dental care, vision, and so on—with no patient cost sharing. The only limitation appears to be cosmetic surgery. The economist who estimated costs for the plan, Gerald Friedman, assumes it would cover 98 percent of all national health expenditures. Health care currently represents 18 percent of GDP, of which the federal government pays for just over half (counting tax expenditures for private health insurance and medical deductions). If the federal government is to become the single payer, it would have to pay for the remaining half, though the additional cost in federal expenditures may be lower if there are net savings and higher if there are net costs.</p>
<p>As Thorpe has detailed <a href="http://prospect.org/article/prospect-debate-cost-sanders%E2%80%99s-single-payer-health-plan">in an exchange with Friedman</a> in the <em>Prospect</em>, Friedman’s estimate of the additional cost to the federal government—$1.38 trillion annually—is too low for several principal reasons:</p>
<p>· First, although health-care goods and services would be available at zero price to consumers, Friedman sees only a 3 percent increase in health-care utilization. Using standard estimates for the effects of reducing out-of-pocket costs to consumers, Thorpe finds a much larger impact.</p>
<p>· Second, the Sanders plan counts on the states continuing to pay their share of Medicaid and the Children’s Health Insurance Program, even though both programs would no longer exist and Supreme Court rulings wouldn’t allow Congress to require states to make such payments for the new federal program.</p>
<p>· Third, in one sector after another, Friedman projects implausible savings—for example, $241 billion out of a projected $350 billion in annual spending on prescription drugs. And he projects an overall growth rate in costs lower than the recent experience of single-payer countries.</p>
<p>Once Thorpe plugs in more realistic numbers, 70 percent of those with private insurance today come out losers under the single-payer plan.</p>
<p>We don’t need to rely on Thorpe’s numbers, however, to predict plenty of resistance to single-payer from the privately insured. <span class="pullquote">People with employer-provided insurance generally see their monthly premium contribution as the price they pay for coverage</span>; they may be only dimly aware of what their employer contributes, and in any event they may not believe they will get that money in higher pay if the government takes over the insurance function. So when they compare their monthly premiums with the tax costs under single-payer, the latter looks worse than if they had full information and knew with certainty that their wages would increase.</p>
<p>Americans with employer-provided insurance may also not be confident of what a government monopoly over insurance would mean for them in the long run. The great appeal of the “public option” proposal in the run-up to the Affordable Care Act was precisely the idea that it would be optional; people wouldn’t be forced into a governmental program. Single-payer implies a federal monopoly on insurance; the government as single payer would become the single decider of all important decisions about technologies, treatments, investments, and so on.</p>
<p>For all its problems, the current system has interested a number of parties—employers, insurers, providers, state governments, and others—in the effort to control health costs and improve the quality of care. Nationalizing the finance of health care implies nationalizing the interest in limiting health-care costs; it eliminates the government’s partners in cost control.</p>
<p>If the United States had adopted national health insurance in the 1940s, when health care represented only about 4 percent of GDP, the health-care system would probably have grown more slowly than it has, primarily because it would have competed for budgetary appropriations with the Defense Department and other claimants on the Treasury. Instead, the United States opted for a mixed, public-private system with high deference to physicians and other health-care interests. That pattern of accommodating private interests led not just to enormous increases in costs but also to a steep barrier for anyone wanting to change the system now. If health care represented as small a percentage of the economy as it did in the 1940s, it would be a lot easier to substitute taxation for private payments. But because health care is 18 percent of GDP today, bringing it all into the federal government requires an enormous increase in taxes.</p>
<p>Even if we could raise taxes to that extent, there would be a question about political opportunity costs. Sanders’s health-care plan (as well as his college-tuition plan) would substitute federal revenue for a great deal of current private and state-government spending. If the federal government used so much revenue for substitution purposes, it would not be able to do other things that aren’t being done now at all. As big as it is, the Sanders agenda leaves a lot out. It puts billions into higher education, but day care, pre-K, and K-12 education don’t get the same priority. Neither do other public needs such as housing. Although his program is highly redistributive, it isn’t particularly concerned with the poor. But once Sanders had raised taxes to Scandinavian levels to nationalize health insurance and much of higher education finance, what could be done about other problems? What would happen if those taxes aren’t even enough to cover the costs of the health-care plan? There is a limit to how much even Bernie Sanders can squeeze out of the rich.</p>
<p>Some of Sanders’s supporters are thrilled with his willingness to back a big expansion of government. If Sanders becomes the Democratic nominee, Republicans may be thrilled too because his tax proposals offer so rich a target in the fall. Democrats owe it to themselves to have a thorough debate about taxes before they find themselves with a presidential candidate whose platform is impossible for most of the party’s candidates for Congress to back.</p>
<p> </p>
<p><em>Note: An earlier version of this article mistakenly attributed figures on marginal income rates in Sanders's tax plan to James Galbraith.</em></p>
</div></div></div>Tue, 12 Apr 2016 20:09:50 +0000224618 at http://prospect.orgPaul StarrThe Democrats as a Movement Partyhttp://prospect.org/article/democrats-movement-party
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap371920160304.jpg?itok=KsXJ5_PI" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Albin Lohr-Jones/Sipa/AP Images</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Following her victories in the Democratic primaries on "Super Tuesday," Democratic Presidential candidate Hillary Clinton spoke at a rally for her supporters, many representing local unionized labor, at the Jacob K. Javits Center in New York City. </p>
</div>
</div>
</div>
</div>
</div>
<p><em>This article is a preview of the Spring 2016 issue of </em>The American Prospect <em>magazine</em>. <a href="https://ssl.palmcoastd.com/21402/apps/ORDOPTION1LANDING?ikey=I**EF1">Subscribe here</a>. </p>
<p><span class="dropcap">P</span>olitical parties in the United States are typically broad coalitions that bring disparate groups together to win elections. In a two-party system, those coalitions are usually the only way the different constituencies and their leaders can hope to gain a share of power. At times, however, parties become closely aligned with social movements that shift the base of party support, or the parties themselves take on the character of a movement. Much of American history is remembered this way—as a series of movements that inspired change in parties, won elections, and transformed the nation.</p>
<p>But that historical memory is selective: Movements haven’t always produced electoral majorities. Their leaders have sometimes miscalculated and brought on their own defeat by driving out elements of the previous party coalition. Since movements bring new energy to parties and imperil old alliances, there is no general rule as to whether they lead to electoral success. They are indispensable to transformative change, but sometimes the transformations they bring about are not the ones they intend and come from victories they hand the opposition.</p>
<p>During the past half-century, the Republican Party has been transformed by the rise of the conservative movement in its various forms, including the Christian right of the 1970s and 1980s, the Tea Party of this decade, and the two insurgencies that have roiled the party this year: Donald Trump’s nativist and protectionist campaign and Ted Cruz’s evangelically based conservatism. If Trump or Cruz and their supporters take control of the GOP, they could radically alter America’s direction from the Obama years and redefine what kind of country this is—or drive enough Republicans out of the party’s coalition in 2016 to hand Democrats a victory.</p>
<p>As the Republicans have moved to the right under movement pressure, the Democrats have shifted to the left, though not to the same degree. To be sure, the party has old ties to the labor, civil rights, and women’s movements and newer ties to movements representing immigrants and LGBT people. Each of these is a distinct constituency with its own agenda. In recent decades, there has been no equivalent on the progressive side to the decisive ideological influence the conservative movement has had on the GOP. Believing they need moderate support to win, state and national Democratic leaders have sought to occupy the middle ground that the GOP’s rightward shift has opened up.</p>
<p>In 2016, however, just as the Republicans face pressure from a party base disappointed with its leaders, so the Democratic Party faces pressure from Bernie Sanders’s surprisingly strong challenge to Hillary Clinton. Clinton is the candidate of center-left party continuity. She falls in the direct line of her husband’s and Barack Obama’s presidencies and has the backing of most of the party’s elected leaders, including most of the progressives in Congress who have endorsed a candidate. Sanders is a movement candidate, an outsider to the party who has throughout his career identified himself as a socialist rather than as a liberal. He’s a man of the left rather than the center left. Until this election, he had always run for office as an independent, frequently denouncing the Democrats as corrupt and beholden to corporate interests and the “ruling class.”</p>
<p>Although many observers have downplayed the difference between Clinton’s and Sanders’s positions, the gulf is considerable. The two candidates’ tax proposals are the clearest measure. To finance free health care, free public college tuition, and other programs that would, in total, expand the size of the federal government by about 40 percent to 50 percent, Sanders has called for 11 different tax increases that would bring top marginal rates on income and capital gains to levels higher than in the two countries he frequently mentions as models, Sweden and Denmark. Clinton wants to extend the Affordable Care Act and other recent Democratic achievements, but she has been cautious on taxes, saying she would favor tax increases only for those making more than $250,000 a year.</p>
<p>As I write in mid-March, Clinton seems likely to be the Democratic nominee. But regardless of how this year’s election turns out, Sanders and his campaign have raised a question about the future beyond 2016—whether the Democrats, like the Republicans, are going to become more of a movement party and what that would mean for American politics.</p>
<p> </p>
<h3>Movement, Party, and President</h3>
<p>The barriers to transformative political change are exceptionally high in the United States. In a parliamentary democracy like Great Britain, a party that wins an election can generally carry out its program because it controls the executive branch as well as the legislature and will not face the voters again for four or five years. In the United States, the separation of powers, the midterm elections for the House, the staggered election of senators, and the role of the Supreme Court all create additional obstacles to large-scale reform. A party intent on transformative change has to win congressional majorities as well as the presidency—and not just once, but repeatedly, in order to carry out a program and, if necessary, shift the ideological balance of the Supreme Court. Control of state governments may also be critical, not least of all because of their power to set rules for elections, gerrymander legislative districts, disempower unions and other bases of opposition, and entrench the status quo.</p>
<p>If the obstacles to transformative change are so great, how have Americans ever brought it about? In “<a href="http://prospect.org/article/broken-engine-progressive-politics">The Broken Engine of Progressive Politics</a>,” a brilliant article published in these pages in 1998, Yale Law professor Bruce Ackerman argued that “the American change machine” has historically had three moving parts. The first has consisted of political movements that “catalyzed sweeping transformations,” from the expansion of democracy in the early republic to Reconstruction, the New Deal, and the civil rights revolution. Second, movements have been linked to parties. Early in American history, rising movements organized new parties—“movement-parties,” Ackerman calls them—from Jefferson’s Democratic-Republicans and Jackson’s Democrats to the Republican Party before the Civil War and William Jennings Bryan’s Populists. The third key element has been the presidency as the focus of transformative leadership.</p>
<p>The central mechanism of political transformation in the 19th century, according to Ackerman, was the combined “movement-party-presidency,” but after the defeat of Bryan and the Populists in 1896, insurgent movements no longer developed into new parties. Instead, the turn-of-the-century Progressives and the feminist, labor, civil rights, and other movements in the 20th century sought influence through one or the other of the major parties, and often both. The role of parties as agents of change diminished. “As parties have grown weaker,” Ackerman writes, “the change engine has worked mainly with two parts—movements and presidents. Today only conservatives seem capable of recreating the classic movement-party-presidency. Progressives will continue to lack a comparable engine for change unless they learn how to put movement, party, and presidency back together again.”</p>
<p><span class="pullquote-right">To put “movement, party, and presidency back together” means revitalizing the missing element—party— and giving it the impetus of a movement.</span> There is little hope for transformative change from electing a president alone without also electing a congressional majority and winning control of major states. Although presidents have considerable power to determine foreign policy, they have little capacity on their own to institute new domestic policies and no power to do so if those involve new taxes. The sustained power necessary to effect change in the American political system—and to avoid devastating midterm reversals and state-level opposition—requires more than campaigns built around an individual presidential candidate. Yet the rise of freelance candidacies and diminished organizational role of parties encourages a focus on building up individuals rather than building institutions.</p>
<p>The preoccupation with personalities and presidents is so strong in America that it even affects those who ought to have a more institutional understanding of politics. Progressives have been prone to magical thinking about the presidency, imagining that presidents can effect change if only movements put enough pressure on them. Activists often illustrate how movements work by telling a story about a delegation of movement leaders who presented their case to Franklin D. Roosevelt while he was president. Sometimes the story is told about labor leaders, sometimes civil rights leaders. Supposedly, FDR responded: “I agree with everything you have said. Now, make me do it.” The quotation is almost certainly fictitious (there do not appear to be any references to it before the 1990s), but like other oft-told tales, the story says more about those who tell it than about its subject. The assumptions are presidentialist. The key word in the line “Make me do it” is “me”—the idea that Roosevelt would urge movement leaders to focus pressure on him rather than Congress and that the president would be the one with the power to do whatever needed doing.</p>
<p>With the benefit of overwhelming Democratic congressional majorities, Roosevelt did bring about a great deal of lasting change. Nonetheless, the New Deal went only as far as Southern Democrats in Congress allowed it to go; when they deserted Roosevelt and allied with Republicans, he was stymied. FDR’s failed purge of conservative Southern Democrats in 1938 ended the possibility of thoroughly remaking the party and recreating the full “movement-party-presidency” Ackerman talks about.</p>
<p>In the next transformative era, the civil rights revolution depended on support from moderate and liberal Republicans in both the judiciary and Congress. When conservative Republicans overreached and nominated Barry Goldwater in 1964, they handed liberals a transformative opportunity, enabling Lyndon Johnson to win a landslide that brought in a large enough Democratic majority in Congress to pass the major programs of the Great Society. Of course, as a previous Senate majority leader, Johnson had a singular ability to get what he wanted out of Congress, and as a Southern successor to John F. Kennedy, he had a lot to prove about his liberal bona fides.</p>
<p>The productive relationships of Roosevelt and the labor movement and of Johnson and the civil rights movement provide the main models for today’s understanding of how progressive movements and presidents bring about change together. But it was only because of big Democratic congressional majorities in 1935 that Roosevelt could pass the Wagner Act and enable industrial unions to organize. It was only because of the breadth of the Democratic landside in 1964 that LBJ was able to pursue the War on Poverty. If recent Democratic presidents haven’t delivered comparable reforms, their personal qualities aren’t the primary explanation, nor is it because movements haven’t made them do it. They haven’t had the sustained congressional majorities they would need, much less the partisan mobilization in the states that would make reform a reality throughout the country. <span class="pullquote-right">The hopes that ride on presidents are destined for disappointment if there isn’t a party capable of carrying them to fruition.</span></p>
<p> </p>
<h3>Building the Party under the Presidency</h3>
<p>Despite winning the popular vote in five of the past six presidential elections, the Democratic Party has been in decline for the past two decades. In their first midterm elections, Bill Clinton in 1994 and Obama in 2010 both lost control of Congress and major states to the Republicans and were severely hamstrung from then on. In his second term, Clinton was able to secure some modest but important policy goals, such as the Children’s Health Insurance Program. But Obama has faced resolute GOP obstruction, and on his watch Democrats have suffered big losses at both the federal and state levels.</p>
<p>Barring a major Democratic sweep, Republican control of the House may be baked into congressional districts until at least 2022, when states will redistrict in the wake of the 2020 census. Currently, of the 99 state legislative chambers, Republicans control 69, a historical record (I count the unicameral legislature in Nebraska as Republican, though it is officially nonpartisan). The GOP has undivided control of 24 state governments, Democrats of only seven—and Republicans are using their power in the states to enact voter-ID and anti-union laws, stack the judiciary, and adopt other measures that will make it difficult to reverse what they have done.</p>
<p>This is the reality that Democrats confront. Electing a president obviously matters for foreign policy, Supreme Court and other judicial appointments, budget appropriations, and the interpretation and enforcement of environmental, civil rights, and other laws. Given the huge gulf between the parties and their presidential candidates, no one should minimize the significance of those differences. But if progressives want large-scale institutional change, the prerequisite is rebuilding the Democratic Party under the presidency and animating it with a progressive agenda.</p>
<p>That is not what’s happening, however, at least not yet. If 2016 were a genuine transformative moment comparable to those in the past, we would be seeing a lot more than a contested presidential primary. We would be seeing more progressive candidates running for Congress and state government; indeed, some of those progressives would already have won office and used their states as “laboratories of democracy” to test out new policies. There are some examples of progressive innovation in cities, but not many in the states. Democrats with those ambitions have yet to show in significant numbers that they can win statewide office, carry out an expansive program, and—in the critical test—get re-elected.</p>
<p>While Sanders and some of his followers are clearly interested in building a movement that lasts beyond 2016, movement-building and party-building are not the same thing. Throughout his career, Sanders has taken pride in not having anything to do with party politics. “Outsider” is his self-description in the title of his autobiography; for decades, he described Democrats and Republicans as Tweedledee and Tweedledum. As recently as 2013, he told <em>The Progressive</em> magazine, “I am not a Democrat.” The writer Ignazio Silone once said the crucial political judgment is “the choice of comrades.” Sanders has had his comrades, but they haven’t been in the Democratic Party. He initially planned to run in 2016 as an independent for president, but in an interview on MSNBC on March 14 he said he became convinced to run as a Democrat because of the media coverage he would get. “In terms of media coverage, you have to run within the Democratic Party,” Sanders told Chuck Todd.</p>
<p>That history of not just standing apart from the Democratic Party but frequently denouncing it helps explain why Sanders has had so little support from elected Democratic leaders. On a practical level, they owe him nothing. He hasn’t raised money for Democrats, and the same arguments he uses against Hillary Clinton for her fundraising would apply to most of them, too.</p>
<p>Beyond 2016, the question is how the model of the Sanders campaign could work as a strategy for party rebuilding on a national scale. The party undoubtedly could use the grassroots-organizing capacity the Sanders campaign has developed. But winning national elections does require raising a lot of money. If money weren’t a factor in the outcome of elections, campaign finance wouldn’t be something to worry about. Sanders’s purism on campaign finance—no super PACs, no big financial donors—can work in states like Vermont with low-cost media markets and in congressional districts with lopsided Democratic majorities. It might even be enough to win a presidential nomination, thanks to all the free media coverage. But it is not feasible in most congressional and statewide elections. Candidates who follow that approach are likely to be outspent by a wide margin, and the difference will doom many of them. That’s why most Democrats who want to reverse <em>Citizens United</em> and see more public financing have nonetheless decided to work within the regime the Supreme Court has established.</p>
<p>This contrast in thinking about campaign finance highlights a broader difference in theories of change. One approach insists on observing ideal alternative rules even if they lead to defeat; the other seeks to make gains under the existing rules in order to get into a position to change those rules. If you want public financing of campaigns, you still have to get legislators elected in a world with private financing. If you want to pass laws strengthening labor and voting rights, you still have to win elections under laws that have weakened labor and voting rights. Before you can change the institutions, you have to use the available resources to your best advantage. If you get ahead of yourself, you may enjoy an initial flash of success, only to suffer a crushing defeat in the end.</p>
<p><span class="pullquote-right">The Democrats do need an infusion of movement energy to confront the deepening inequalities in American life. </span>They also need to take advantage of the opportunities in the center that a radicalized Republican Party creates for them. Taking advantage of those opportunities in 2016 may be the best way to create the preconditions for more substantial change; Supreme Court nominations are the first and most obvious way. If one party goes to an extreme and hands the other side the chance of a big victory, the other party would be foolish to miss its chance. The precedent for 2016 could turn out to be 1964. And in the long run, it’s a close call as to whether America would benefit more if Democrats became more of a movement party or if the GOP reacted to a loss in 2016 by becoming less of a movement party.</p>
<p>The tumult of the 2016 presidential primary season has led to some brash judgments about the parties’ future. I am reluctant to jump to any conclusions. There isn’t enough confirming evidence from trends in congressional or state elections or public opinion surveys to demonstrate that the two major parties are moving for the long term in the directions represented by Trump and Cruz, on one side, and Sanders on the other.</p>
<p>But there is no doubt about how big the immediate choices are. The voters this year are not just choosing between different candidates and parties. They are choosing between different Americas. After November, we should have a much clearer idea about what kind of country we live in.</p>
</div></div></div>Tue, 29 Mar 2016 09:00:00 +0000224437 at http://prospect.orgPaul StarrWhat If Trump Had Run as a Democrat?http://prospect.org/article/what-if-trump-had-run-democrat
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap1603132105152805.jpg?itok=Hs7Wb3or" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/John Minchillo</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Republican presidential candidate Donald Trump works the rope line during a campaign stop at the Savannah Center, Sunday, March 13, 2016, in West Chester, Ohio. </p>
</div>
</div>
</div>
</div>
</div>
<p><span class="dropcap">A</span> number of observers have said Donald Trump’s march to the Republican presidential nomination is a case of chickens coming home to roost. And it’s true: The GOP has for years been playing to white resentment, and Trump has just exploited that potential more aggressively than anyone else. From this standpoint, the Republican Party’s leaders have no one to blame but themselves for the hijacking of their party.</p>
<p>But let’s play a little “alt” history and imagine that several years ago, Trump began calculated moves to run as a Democrat. Let’s imagine also that Beau Biden had never developed brain cancer, and that his father, Joe, had decided to run for president, so the “mainstream” Democratic vote was more divided.</p>
<p>Planning to run as a Democrat, Trump would have avoided backing the “birther” movement, but could have made other inflammatory charges (for example, against Hillary Clinton) to get media attention. To build Democratic support, he could have staked out positions in favor of single-payer health care, more progressive taxes, and a massive infrastructure program, while denouncing trade agreements, the war in Iraq, and illegal immigration. With only a slight shift from his current stances, he could have presented himself as an economic populist with business know-how who gets along famously with unions and working people, and is both a ferocious nationalist and a skeptic about foreign wars. In short, he could have wrapped his protectionism and nativism in a package more appealing to the left.</p>
<p>With Trump dominating media coverage of the Democrats and with Biden taking away votes from Clinton, the Democratic field this year might have looked like the fractured field the Republicans have had. In this scenario, the two mainstream Democrats—Biden and Clinton—would have been flanked by two populists: Trump and Bernie Sanders. Because of the overlap of their positions on trade, health care, taxes, and the War in Iraq, Trump and Sanders would have appealed to many of the same voters. The independents who have flooded into the Republican primaries to vote for Trump would have voted in the Democratic primaries instead.</p>
<p>Whether Trump would have won that four-way race is anybody’s guess. <span class="pullquote-right">But it might have been sufficiently close that right now we’d be talking about the likelihood of a contested Democratic convention in Philadelphia in July.</span></p>
<p>But here’s where things would differ: The Republican Party’s delegate-selection rules make a Trump victory more likely than the Democratic rules would have. As an article in <em>FiveThirtyEight</em> points out, “Donald Trump Would Be Easy to Stop Under Democratic Rules.”</p>
<p>The primary reason is that the Republican rules give a bonus in delegates to the frontrunner, whereas the rules in the Democratic race award delegates proportionally. If Trump were running as a Democrat with the same vote-share he’s received as a Republican, he would be much less likely to reach the target for a first-ballot nomination.</p>
<p>In addition, the Democrats have more superdelegates, who would be more likely to back the party’s mainstream candidates. The Democratic superdelegates get a lot of bad press, but they provide some protection against the hijacking of the party by a demagogue.</p>
<p>It may be hard now to visualize Trump as a Democrat, but he could have easily chosen to use the Democratic Party as the vehicle for his ambitions. All he had to do was to recalibrate his positions and his rhetoric a few degrees. Democrats can count themselves lucky he opted to run as a Republican.</p>
</div></div></div>Thu, 17 Mar 2016 12:33:18 +0000224375 at http://prospect.orgPaul StarrThe Larger Problems of the Sanders Single Payer Planhttp://prospect.org/article/larger-problems-sanders-single-payer-plan
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><em>This is a contribution to <a href="http://prospect.org/article/prospect-debate-cost-sanders%E2%80%99s-single-payer-health-plan">Prospect Debate: The Cost of Sanders's Single-Payer Health Plan</a>. </em></p>
<p></p><div class="media media-element-container media-full"><div id="file-22149" class="file file-image file-image-jpeg">
<h2 class="element-invisible"><a href="/file/22149">prospect-debates-icon.jpg</a></h2>
<div class="content">
<img alt="" class="media-image" height="109" style="width: 109px; height: 109px; margin: 10px; float: right;" width="109" src="http://prospect.org/sites/default/files/prospect-debates-icon_20.jpg" /></div>
</div>
</div>
<p><span class="dropcap">T</span>hink about what a single-payer health plan means. The federal government pays for all health care for everyone. The pleasant thought is that all of your health expenses are being paid for. The unpleasant thought is that since all those expenses come out of the federal budget, your health care now depends on the decisions of Congress and the president. And an even more unpleasant thought—at least for progressives who may be inclined to support single-payer—is that people with progressive values will not always be in charge in Washington and therefore wouldn’t always be making those decisions.</p>
<p>In “<a href="http://prospect.org/article/false-lure-sanders-single-payer-plan">The False Lure of the Sanders Single-Payer Plan,”</a> I raised a series of objections to Sanders’s proposal. Responding from the Sanders camp, Gerald Friedman devotes all his attention to one aspect of my criticism: the cost estimates by Kenneth Thorpe that I cited. Joining in the debate, Thorpe has now shown again in devastating detail why Friedman’s cost estimate is far too low and consequently why the savings that Sanders is promising would not materialize.</p>
<p>Here I want to return briefly to three other arguments I made that Friedman never addresses: 1) the taxes and opportunity costs of the Sanders plan; 2) the excessive centralization of power implicit in his plan; and 3) the misleading lessons that Sanders and his supporters draw from the experience of other countries.</p>
<h3>Taxing to the Limits—and Beyond</h3>
<p>Even if we accept Friedman’s lowball estimates of the cost, the Sanders plan would require staggering increases in federal taxes. Those increases raise two kinds of questions—about the feasibility of the taxes and about the opportunity costs of using so much tax revenue to substitute for private health expenditures.</p>
<p>Sanders calls for six different increases to fund single-payer. Two of the changes—a new payroll tax of 6.2 percent and a new income tax of 2.2 percent—would affect everyone. The other four increases fall primarily on high-income households (higher income tax rates, taxing capital gains as ordinary income, eliminating deductions, higher estate taxes). Both sets of tax increases create serious political problems.</p>
<p>As a result of the first set, the post-tax income of Medicaid beneficiaries (who now receive coverage for free) would fall 8.4 percent. Other low- and middle-income people, to be sure, would get coverage worth more than 8.4 percent of their income, but they might not think so. For households with incomes between $18,550 and $75,300, for example, marginal tax rates (payroll and income tax combined) would rise from 30.3 percent to 38.9 percent. That will be a hard sell. Whether people at that income level with employer-provided insurance would objectively be winners or losers under the Sanders plan depends on whether Friedman’s or Thorpe’s cost estimates are right. (Thorpe estimates that 70 percent of the privately insured come out losers.) But, subjectively, even many winners would see themselves as losers because they don’t feel that their employer’s health-insurance payments were their money to begin with. Perceptions bias calculations against a tax-financed alternative.</p>
<p>The tax increases affecting high-income households raise other problems. I am in favor of more progressive taxes, but there is no peacetime precedent in American history for increases of the magnitude Sanders is talking about. In his health care and other proposals, Sanders proposes raising the top marginal rate on earnings (income taxes and payroll tax combined) to 77 percent—higher than in Sweden (67 percent), Denmark (55.6 percent), or any other European country. The capital-gains tax rate that Sanders is proposing (64.2 percent, not counting his financial transaction tax) would so high as to be counterproductive. At that level, the tax wouldn’t generate the expected revenue. People would hold on to appreciated assets rather than sell them, and capital would be locked into present uses, depressing new investment.</p>
<p>We need more tax revenue, but we need to find it at more reasonable rates and with a wholly different approach (see my article, <a href="http://prospect.org/article/how-gilded-ages-end">“How Gilded Ages End,”</a> Spring 2015, for a strategy that emphasizes attacking tax privileges). Moreover, we need that revenue to do things that aren’t being done now—not to substitute for hundreds of billions of dollars in current private health spending. The Sanders health plan imposes an enormous opportunity cost from a progressive standpoint. All that tax money substituting for private premiums is money that isn’t available for other public purposes. Once you get to 77 percent marginal income-tax rates, where do you go next if your cost estimates have been too low or for any of the many public purposes not served by Sanders’s program?</p>
<h3>Excessive Centralization of Power</h3>
<p>The single payer in Sanders’s plan is the federal government. The plan effectively removes any interest in controlling health costs not only from patients and providers, but also from employers and other levels of government, including states. If the federal government is the only institution with a stake in controlling health costs, it will have to do all of the controlling.</p>
<p>Over the years, other universal-coverage proposals have generally retained some sharing of the costs by patients, employers, and state governments so as to give them an interest in monitoring and checking cost increases. This was the case under the 1993 Clinton health plan, and it is also true of the Affordable Care Act, which emphasizes the principle of “shared responsibility.”</p>
<p>It is not clear from Sanders’s proposal whether he is proposing an individual legal right to free health care—that is, an “entitlement” that would be automatic from year to year and not come under the discretionary part of the budget that Congress needs to approve annually. Moving all health expenditures—17.5 percent of the economy—onto federal taxpayers as an entitlement exposes the Treasury to much greater risk than the more limited federal expenditures for Medicare and Medicaid (the latter, of course, shared with the states). If health care isn’t a federal legal entitlement and funds have to be decided on every year, health care would continually be up against every other rival for budgetary appropriations, including the military. Of course, Congress can modify entitlements, too, so either way it would ultimately decide not just total spending but many aspects of health care that are today one or two removes away from the political process.</p>
<p>Some of the defenders of the plan may point to Medicare and see nothing to worry about. But the existing Medicare program and Sanders’s plan are very different. Medicare has patient cost-sharing and limits on the scope of coverage, which Sanders would do away with. (Sanders’s term “Medicare for all” is a misnomer; Medicare as we know it would be abolished.) Once the federal government pays for all of health care for people of all ages and incomes, providers would no longer be in the position of making up their losses on Medicare and Medicaid patients by charging more to the privately insured. Everything would then depend on decisions in Washington about such questions as whether new treatments would be covered and what prices would be paid. </p>
<p>Sanders has not been forthright in acknowledging that concentration of payment implies concentration of power. No doubt Americans would love to have all their health care paid for. Whether they would like to centralize those decisions in the federal government is another matter.</p>
<h3>Misleading Lessons from Abroad</h3>
<p>Sanders and his supporters misrepresent the experience of other countries. Many countries with universal coverage have multiple insurance funds and still have much lower costs than in the United States. Concentrating payment in a single payer—and making the national government that payer—is not the essential requirement for an improved health-care system. Canada, so often cited as the model of single-payer, organizes and finances health care at the provincial level. Other countries with multiple payers have regulatory and bargaining arrangements that keep costs under control.</p>
<p>Most of the European countries with national insurance systems introduced their programs long ago, when health care was a small fraction of their economy. They did not have to expropriate a highly developed private insurance system. The challenges are altogether different when health care represents more than one-sixth of the economy and private institutions are already in place serving the same functions as a federally financed and controlled system. Just as other countries generally built on their previous institutions, so can the United States.</p>
<p>The Affordable Care Act provides a framework that makes further progress possible. As I suggested in my article, it could be a basis for pursuing some reforms close to what single-payer advocates want. One of the most practical possibilities would be a Medicare buy-in for people aged 55 to 64. Another possibility would be to use the state waivers soon available under the ACA for public-option experiments at the state level. That process could even be pursued without any congressional action under a Democratic president, if one is elected in 2016. But that president would have to work creatively to make the most of the institutional possibilities at hand, instead of engaging in what would be a hopeless crusade for a proposal that will go down to defeat again, as it has every time it has come up before. </p>
</div></div></div>Mon, 29 Feb 2016 10:00:00 +0000224235 at http://prospect.orgPaul StarrIsolationism is No Answerhttp://prospect.org/article/isolationism-no-answer
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><em>This is a contribution to "<a href="http://prospect.org/article/prospect-debate-should-we-fight-isis">Prospect Debate: Should We Fight ISIS?</a>"</em></p>
<p></p><div class="media media-element-container media-full"><div id="file-22049" class="file file-image file-image-jpeg">
<h2 class="element-invisible"><a href="/file/22049">prospect-debates-icon.jpg</a></h2>
<div class="content">
<img alt="" class="media-image" height="109" style="width: 109px; height: 109px; margin: 10px; float: right;" width="109" src="http://prospect.org/sites/default/files/prospect-debates-icon_14.jpg" /></div>
</div>
</div>
<p><span class="dropcap">I</span>n his response to <a href="http://prospect.org/article/accelerating-fight-against-isis">my article</a> in the Winter issue, Jeff Faux calls for the United States to abandon the fight against ISIS and to withdraw from the Middle East. This is not a good idea.</p>
<p>ISIS and al-Qaeda, it should be unnecessary to say, represent real threats to the security of people around the world, including Americans. Neither terrorist group is going to stop killing infidels if the United States pulls out. Learning about their intentions is not difficult. They have made those intentions abundantly clear in public statements and videos and through the language of violence.</p>
<p>It is not true that all the efforts by the United States to defeat terrorism have failed and that the war against ISIS is “already lost,” as Faux claims. In fact, the measures we have taken against al-Qaeda have severely weakened it, and ISIS is now in retreat in its home territory in Syria and Iraq. In his wholesale condemnation of U.S. policy, Faux fails to make critical distinctions. The original war in Afghanistan after September 11 was fully justified, and it succeeded. What was not justified (and what <a href="http://prospect.org/article/liberal-uses-power">we at the <em>Prospect</em> consistently opposed</a>) was the Iraq War, which did have perverse consequences in destabilizing the region.</p>
<p>But we are now at a different moment, faced with new challenges. Two distinct, albeit overlapping, wars are taking place in Syria: the war between rebel groups and the Assad regime (which the regime now seems to be winning), and the war (extending into Iraq) in which allied forces are trying to roll back and destroy ISIS.</p>
<p>The United States cannot ignore the wider stakes in each conflict. The Syrian civil war has brought about four separate disasters: 1) the horrors being visited on the Syrian people; 2) the flood of immigrants into Europe; 3) the right-wing reaction in Europe being fed by that flood; and 4) the growth of ISIS, which has gone from murdering and enslaving members of religious minorities in the region to launching attacks in Paris and elsewhere.</p>
<p>Those attacks, as I wrote in the <em>Prospect</em>’s winter issue, pose a distinctly political danger. They are “a boon to the right in Europe and America,” while “the right’s indiscriminate threats against Muslims at home and abroad are a boon to the jihadists.” The two extremes feed off each. “During the next year, there is no greater challenge than stopping that spiral.”</p>
<p>The way to stop that spiral is for the United States and its allies to demonstrate—in months rather than years—that a disciplined and discriminating strategy can defeat ISIS and put the Syrian civil war on the path to a peace accord.</p>
<p>In the past year, U.S.-aided allies—mainly the Kurds in eastern Syria and Iraqi army in western Iraq—have recovered one-third of the territory that had been under the control of ISIS. The fall of Ramadi was a major step. Ignoring the destruction and carnage that ISIS itself caused, Faux attributes the devastation of Ramadi entirely to American airstrikes. If he had been writing during World War II, he could have made the same argument against attacking the Nazis (and, from the standpoint of religious minorities, the comparison of ISIS to the Nazis is a perfectly apt analogy).</p>
<p>With our support, the Kurds and Iraqis are continuing to advance against ISIS; the campaigns to retake Mosul and Raqqa have already begun. I wrote my article to encourage accelerating those efforts in the hope that their success could take the wind out of the belligerent, anti-Muslim policies in immigration and foreign affairs advocated by Donald Trump, Ted Cruz, and others on the right.</p>
<p>Faux not only rejects any U.S. effort to fight ISIS; he also questions whether the United States can secure help in that effort from Arab allies. In response to my statement that we should accept such offers from Arab states, Faux asks, “What offers?” To be specific, from the Saudis and the emirates—see “<a href="https://www.washingtonpost.com/news/checkpoint/wp/2016/02/12/u-s-arab-allies-pledge-ground-troops-to-battle-islamic-state/">U.S. Arab allies pledge ground troops to battle Islamic State</a>.” </p>
<p>It’s interesting that Faux should be so dismissive of any effort to mobilize Arab allies against ISIS. That is the cornerstone of Bernie Sanders’s proposal in fighting ISIS, which the Vermont senator has said repeatedly would be his top foreign-policy priority. But Faux’s position is far to the left of Sanders as well as Clinton. He just wants the United States to give up and do nothing about ISIS, al-Qaeda, or any terrorist groups or other threats that emerge abroad.</p>
<p>In regard to Syria, Faux misrepresents a widely discussed idea for a settlement that I mentioned in my piece. He says I suggested Syria “be carved into three parts.” In fact, here is what I wrote: “The best hope now may be a federal system that would divide Syria into ‘cantons’ with substantial autonomy for groups like the Kurds.” Federalism is a common basis for resolving civil wars; it means devolving power downward to regional governments, not “carving up” a state. In December, when I wrote the article, there was reason to hope that a negotiated settlement of that kind might be possible. Now, with the Russians tilting the civil war in the regime’s favor, there doesn’t appear to be much hope for a balanced resolution.</p>
<p>Despite the direction events have taken since the Russian intervention, I don’t believe there were ever good prospects in Syria for a victory by “moderate” rebels against the Assad regime. Obama made the right decision to hold back from any substantial involvement in that conflict. Where he should have responded more quickly and forcefully was against the rise of ISIS.</p>
<p>In the fight against ISIS, there is a reasonable argument about how large a commitment of special forces and other troops the United States should make. We don’t want to field an occupying army, but neither can we avoid putting military resources into the conflict. There is also a reasonable argument to be made about how to limit civilian casualties in airstrikes, as the U.S. military has, in fact, been trying to do. And, when the time comes, there will be a reasonable argument about responsibilities for postwar reconstruction in the areas of Syria and Iraq where ISIS has held power and been driven out.</p>
<p>But, for now, there is a fight to be won. As uncomfortable as the choices are, we cannot run away from the Middle East and hope that ISIS and other terrorist groups will just leave us alone. The world is too small, and the United States is too easily reachable from abroad.</p>
<p>One of the many ill effects of George W. Bush’s disastrous decision to go into Iraq is the encouragement it has given to isolationism on the left. Turning our backs on the world—or perhaps I should say “turning the other cheek” since Faux is recommending we run away even when Americans are attacked—is the wrong lesson to take from the disastrous decisions Bush made. The better lesson is to use American power judiciously but decisively when there are American and humanitarian interests at stake. In the fight against ISIS, that is exactly what we need to do.</p>
</div></div></div>Mon, 22 Feb 2016 10:00:00 +0000224167 at http://prospect.orgPaul StarrThe False Lure of the Sanders Single-Payer Planhttp://prospect.org/article/false-lure-sanders-single-payer-plan
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><div class="embed">
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap_472966715593.jpg?itok=3c8N5gqi" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">(Photo: AP/Evan Vucci)</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Democratic presidential candidate Senator Bernie Sanders speaks during a campaign rally in Cedar Rapids, Iowa, on January 30.</p>
</div>
</div>
</div>
</div>
</div>
<p><span class="dropcap">W</span>ouldn’t it be great if we could just go to the doctor and not pay any bills? After all, isn’t that what they do in other countries, and don’t those countries have lower health-care costs than the United States does? And aren’t private insurance companies the only reason we don’t have that kind of system?</p>
<p>This is the appeal of the Bernie Sanders single-payer health plan. Free health care, with none of the frustrating paperwork of today’s insurance, and with taxes that cost less than insurance premiums—what could be better than that? Of course, the single payer in the Sanders plan is the federal government, which implies concentrating payment and therefore power over health care in Washington. But, at least in this area, many Democrats don’t seem worried about that prospect.</p>
<p>Sanders doesn’t just call for incremental steps toward single-payer. He’s proposing to shift all of health care to federal taxes in one fell swoop. That’s one reason for the enormous, sudden increase in taxes the plan would require—$1.38 trillion on top of existing federal spending, according to Sanders’ own estimates. As <a href="http://www.vox.com/2016/1/16/10779270/pollack-single-payer-in-america">Harold Pollack has pointed out</a>, that $1.38 trillion is just about equal <em>to total federal income and estate tax collections in 2014</em>—in other words, the plan would require doubling that revenue. Sanders insists that he’s shown how he would pay for it through a 6.2 increase in payroll taxes (which he calls an “income-based premium paid by employers,” though the cost will fall on employees); a 2.2 percent increase in income taxes on everyone; higher estate taxes; taxing capital gains and interest as ordinary income; limiting tax deductions for the rich; and higher income-tax rates on the upper brackets (which, combined with other increased taxes he’s also calling for, would bring the top marginal federal rate to 77 percent, as <a href="http://www.vox.com/2016/1/22/10814798/bernie-sanders-tax-rates">Dylan Matthews shows</a> at Vox).</p>
<p>But Sanders’s estimate of the needed increase in taxation, despite its whopping size, is too low. The plan would actually cost another $1.1 trillion a year, according to <a href="http://www.scribd.com/doc/296831690/Kenneth-Thorpe-s-analysis-of-Bernie-Sanders-s-single-payer-proposal#scribd">an analysis by Kenneth Thorpe</a>, a health-care economist at Emory University, who has long experience working with single-payer proponents. In 2006, the Vermont legislature hired Thorpe to cost out a single-payer proposal, and in 2014 progressive legislators in Vermont hired him again. So this is not an estimate from an economist generally opposed to universal health care or to single-payer. Thorpe’s estimates indicate that workers would have to pay an additional 20 percent of compensation to pay for Sanders’s plan.</p>
<p>At Vox, Matthews has probed both Thorpe and the Sanders campaign on some of the specific areas where their numbers diverge. Here’s one stunning detail: When the Sanders campaign released its plan, it estimated $324 billion in annual savings on prescription drugs—until Thorpe noted that the United States spent only $305 billion for that purpose in 2014. (If Trump can expect Mexico to pay for a wall on the border, I suppose Sanders can expect drug companies to pay consumers instead of the other way around.) When Matthews pointed out that it was impossible to save $324 billion out of $305 billion, the Sanders camp cut their savings estimate to $241 billion, while conveniently increasing other projected savings to make up the difference. But $241 billion in drug savings are still implausible, and as the entire episode indicates, the Sanders campaign is simply pulling numbers out of the air.</p>
<p>The Sanders’s plan also makes implausible assumptions about health-care spending by the states. While eliminating the Medicaid program, Sanders counts on states to continue spending what they now spend on Medicaid, even though the Supreme Court has ruled that the federal government cannot require the states to spend money on a program—especially one that no longer exists.</p>
<p>Why does the Sanders plan cost so much? Among other reasons, the plan calls for eliminating all patient cost-sharing. I’m not a fan of high co-pays and deductibles, but eliminating them altogether will increase health spending more than Sanders acknowledges. His plan also includes no limits on the scope of coverage. “Bernie’s plan,” the campaign says, “will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral healthcare; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments.” This is an extraordinary list; long-term care alone is spectacularly expensive. Although Sanders refers to his plan as “Medicare for all,” it is far bigger than Medicare, which has never eliminated cost-sharing or covered all these services.</p>
<p>Let’s leave aside whether even a Democratic Congress could pass tax increases of the magnitude Sanders’s plan would require. There’s also a question of priorities: Should Democrats—should anyone—support devoting so much federal revenue to health care? The country has a lot of other needs. Transferring all private health spending to the federal treasury is not necessarily the best use of federal tax capacity. Sanders’s health plan is so costly it would make it impossible to do much else.</p>
<p>It’s not just private insurers that would stand in the way of this plan. Thorpe estimates that 70 percent of people with private insurance would end up paying more than they do today.</p>
<p>But what about other countries that Sanders often cites? Don’t those examples show that a system of national health insurance is cheaper and better than one with private insurance?</p>
<p>Here’s where I agree with that argument: If we could wind back the clock to the 1940s, when health care was just 4 percent of GDP and private insurance was just beginning to develop, we might well be able to design a national insurance program—as Harry Truman proposed—that would have kept down the growth of costs. But we can’t wind back the clock. In the mid-to-late 20th century, a very different system developed with the rise of both private, employer-based insurance and the adoption of public programs that accommodated the interests of physicians and hospitals.</p>
<p>This is a story I’ve told in two books—<em>The Social Transformation of American Medicine</em> (1983) and <em>Remedy and Reaction</em> (revised edition, 2013). The financing arrangements that emerged in the United States had two complementary effects: They created incentives for high-cost specialized care and protected much of the public from the full, direct cost of that system. As a result, starting from 4 percent of GDP, health care grew to 17.5 percent, far more than in any other country. That level of costs is reflected in investments in medical technology, the physical infrastructure of hospitals and other facilities, the patterns of medical training and specialization, and the size and structure of the health-care labor force. Adopting a government insurance plan won't undo a system that's been built up over decades, though it would certainly alter its future evolution.</p>
<p>While having the federal government take over all private health expenditures (and state and local government spending too, unless Sanders can also appoint new justices to the Supreme Court), the Sanders plan attempts to squeeze per capita health expenditures down to Canadian levels. The plan doesn’t explain how it is going to bring this about, and Thorpe’s analysis says it won’t. But if the federal government did impose sufficient controls, the results would be to bankrupt many institutions that are counting on future streams of revenue to cover debt payments, meet payroll, and satisfy other obligations. </p>
<p>The Affordable Care Act does not try to roll back spending levels to the share of GDP that health care represented decades ago. It has the limited, uninspiring, but ultimately more sensible goal of “bending the cost curve”—slowing the rate of growth of health-care costs, which has actually happened in the years since the law’s passage.</p>
<p>The ACA is far more in keeping with the lesson to be drawn from the history of health policy in other countries. Most countries have built on their existing institutions as they have pursued universal coverage and sought to control costs. The governments that instituted unified national insurance systems generally did so before private insurance had developed on a large scale. Many countries that had multiple insurance funds have maintained them; rather than centralizing all payment, they have created regulatory and negotiating arrangements that keep costs in check. This is the direction we can and should take.</p>
<p>In the wake of the adoption of the ACA—if it isn’t repealed by Republicans—the United States could adopt additional reforms to improve coverage and control costs, including measures opening Medicare to wider enrollment. One possibility is to provide a basis for 55-to-64-year-olds to buy into Medicare. The idea of a Medicare buy-in was supported by Bill Clinton in the late 1990s and by Al Gore in the 2000 election campaign. It is even more practical now as a result of the ACA’s individual mandate, which reduces the likelihood of adverse selection (higher enrollment by those with high medical costs). A Medicare buy-in came up late in the 2009 Senate debate about the ACA as an alternative version of the “public option,” but it died as a result of Joe Lieberman’s objections and worries among other Democrats about its impact on the financial stability of hospitals in their states—a concern that would have to be dealt with in any effort to revive the idea.</p>
<p>I mention a Medicare buy-in for people in the decade before full Medicare eligibility only to illustrate the kind of incremental measure that is both practical and consistent with the aspirations of many progressives. It would be difficult to enact, but it wouldn’t require a Sanderista revolution and heroic assumptions about Americans’ support for increased taxation.</p>
<p>Sanders’s single-payer plan is not a practical or carefully thought-out proposal. It’s a symbolic gesture, representative of the kind of socialism he supports. The question that Democratic primary voters will have to answer is whether they want their party to go into a general election with a gesture of this kind.</p>
</div></div></div>Mon, 01 Feb 2016 10:00:00 +0000223980 at http://prospect.orgPaul StarrAccelerating the Fight Against ISIShttp://prospect.org/article/accelerating-fight-against-isis
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p></p><div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap873276900024.jpg?itok=KVmS4ewU" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Jacquelyn Martin</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>President Barack Obama addresses the nation from the Oval Office at the White House in Washington, Sunday night, December 6, 2016. The president's speech followed Wednesday's shooting in San Bernardino, California, that killed 14 people and wounded 21. </p>
</div>
</div>
</div>
</div>
<p><em>This article will appear in the Winter 2016 issue of </em>The American Prospect <em>magazine</em>. <a href="https://ssl.palmcoastd.com/21402/apps/ORDOPTION1LANDING?ikey=I**EF1">Subscribe here</a>. </p>
<p><span class="dropcap">W</span>e are at a dangerous moment in the interplay of foreign and domestic politics. Jihadist attacks are a boon to the right in Europe and America, and the right’s indiscriminate threats against Muslims at home and abroad are a boon to the jihadists. This is a familiar cycle, a spiral of violence and fear in which the extremes feed off each other. During the next year, there is no greater challenge than stopping that spiral.</p>
<p>In the United States, the challenge takes on particular urgency because of the 2016 election. Donald Trump and other Republican candidates play upon public anxieties, fanning hostility to Muslims and promising a more aggressive military response to terrorism. Ted Cruz says, “Barack Obama does not wish to defend this country,” whereas he would “carpet bomb” the Islamic State in Iraq and Syria (ISIS). Trump also promises to “bomb the hell” out of the enemy and wreak vengeance on the families of terrorists, while calling Obama and the other candidates “weak” and “stupid.” The campaign has already degraded public discourse; the election could produce a sharp swing toward a bellicose xenophobia.</p>
<p>While Republicans bluster, the president has calmly insisted that the strategy he is following is the smart and ultimately more effective way to defeat ISIS and al-Qaeda. That strategy involves negotiating a cease-fire and resolution of the civil war in Syria and building an international military coalition to defeat ISIS. Emphasizing his opposition to a large American ground war, Obama has nonetheless committed some forces to the fight against ISIS—limited special forces in Syria and a larger number of troops in Iraq. That line has been crossed.</p>
<p>But will this effort be sufficient to make demonstrable progress soon enough—in particular, before next November’s election? The longer ISIS enjoys the power and resources it now has, the more risk there is of additional attacks on Western cities, with increasingly dangerous political repercussions. ISIS’s offshoots and affiliates now operate in Libya and other countries. The hope among defenders of Obama’s approach is that as a quasi-state in its home territory, ISIS will collapse under pressure. This is a plausible scenario, and steadily applying the necessary pressure would be the right way to proceed if there were no urgency to the situation.</p>
<p>Unfortunately, despite some success in recapturing territory from ISIS, there is reason to be skeptical that the president’s current approach will result in unmistakable progress, let alone the defeat of ISIS, by November. If for that reason alone, Hillary Clinton and other Democrats running in 2016 will need to put some distance between their position and Obama’s without repudiating the president. They will also need to provide voters with an alternative language of power and protection that explains why the simplistic and reckless approach on the right endangers Americans’ true safety and security.</p>
<p> </p>
<p><strong>THERE IS PROBABLY</strong> no better illustration of the inadequacy of simplistic ideas about the world than the two wars currently unfolding in Syria. One war pits rebel forces against the Assad regime, while the other (which also extends into Iraq) pits allied forces against ISIS. In each war, the local combatants are backed by external powers, but the alliances in one conflict do not match those in the other. For example, Russia and Turkey are on opposite sides in the Syrian civil war but are at least nominally on the same side in the war against ISIS. Anyone who assumes that the world is divided between good guys and bad guys and that we can protect ourselves by “bombing the hell” out of the bad guys will have a hard time understanding these wars, much less providing effective American leadership.</p>
<p><span class="pullquote-right">In both the diplomatic and military efforts under way, there is no way to avoid working with bad guys.</span> In the civil war, the rebel forces fighting Assad include many such evildoers—exponents of “radical Islam,” as Republicans like to say—whose cooperation is essential to a settlement. In the fight against ISIS, the United States is relying primarily on Kurdish troops organized under a front group for the Kurdistan Workers’ Party, known as the “PKK,” which the U.S. government designated a “terrorist organization” in 1997. Under the pretense that this is not so, American officials avoid mention of the PKK front, referring to the somewhat broader “Syrian Democratic Forces” (SDF), though no one in the region is fooled. To make matters even more complicated, the PKK has ties to Russia and in some cities divides control with the Assad regime rather than making war against it.</p>
<p>Since air power alone is insufficient to defeat ISIS, there need to be troops on the ground to complement U.S. airstrikes, and the Kurds have been the main source. As of mid-December, the combination of Kurdish ground operations and U.S. airpower had driven ISIS back from areas in northeast Syria close to the Turkish border that are primarily Kurdish. But to continue south and seize Raqqa—ISIS’s administrative center—requires taking Sunni Arab territory. “The plan seems to be,” writes Aron Lund, editor of <em>Syria in Crisis</em>, “to use the SDF to gradually glue more Arab groups onto a Kurdish core force while also separately <a href="https://news.vice.com/article/syrias-newest-rebel-army-has-its-sights-on-the-islamic-state">standing up a nucleus of Sunni Arab fighters who belong to eastern Syrian tribes</a>. Realistically speaking, these groups won’t be strong enough to dispense with the Islamic State and establish <a href="http://carnegieendowment.org/syriaincrisis/?fa=59367">sustainable local governance</a> on their own, and … there is a limit to how far south you can go with the Kurds.”</p>
<p>In his speech from the Oval Office on December 6, Obama said, “The strategy that we are using now—airstrikes, special forces, and working with local forces who are fighting to regain control of their own country—that is how we’ll achieve a more sustainable victory.” That strategy could work if there were local forces to carry it out. But as <em>Washington Post</em> columnist David Ignatius and others have pointed out, we have thus far failed to win over the local Sunni Arab fighters that the strategy requires. Iraq’s Shia-dominated government has been a primary obstacle to getting that Sunni support.</p>
<p>In his December 6 speech, Obama also argued that the international efforts to settle the Syrian conflict could, if successful, allow countries allied with the United States as well as others, including Russia, “to focus on the common goal of destroying” ISIS. That, too, could work, but such a coalition will need to put troops into the field. Many of them may be “local” (at least in a regional sense), but the United States will almost certainly have to share directly in the ground operations. </p>
<p>Again, the question is how quickly things will move. The Syrian conflict has already gone on for an obscene length of time, creating a humanitarian disaster and a flood of refugees that has destabilized European politics. Much depends now on Vladimir Putin’s calculations of Russia’s interests. While Syria could become a quagmire and weaken Putin at home, Russian intervention has fortified the Assad regime, and advances on the battlefield could strengthen the regime’s hand in negotiations. Whether Putin and Assad favor a cease-fire sooner or later may depend on how they read their military prospects. </p>
<p>On the other side, the rebel groups backed variously by the Gulf States, the West, and Turkey have had deep and persistent differences and show little promise of bringing peace or justice to Syria. The best hope now may be a federal system that would divide Syria into “cantons” with substantial autonomy for groups like the Kurds. But any such resolution would make Turkey nervous because of the PKK, with which it has long been at war. The Kurds were barred, partly at Turkey’s insistence, from the recent conference in Riyadh of Syrian opposition groups that created a joint commission to choose a negotiating team for peace talks with the Assad regime. Those talks are scheduled to begin in January in New York, but the continuing divisions among the Syrian opposition, as well as the conflicting interests of their foreign patrons, create innumerable stumbling blocks in the path to a settlement.</p>
<p>In short, Obama’s strategy—at least so far—lacks either the necessary local ground forces or the means of securing an expeditious resolution of the Syrian civil war and refocused international efforts to defeat ISIS. The United States could ramp up the fight against ISIS, as Clinton has suggested, by arming the Sunnis. We could also accept offers of ground troops from Arab countries and increase the size of the very limited force of our own that Obama has so far committed. Those forces could tip the balance in pending battles with ISIS. In the Syrian civil war, the United States and its allies may need to accelerate a deal with Russia that reflects both the battlefield realities and the limits (and limitations) of the opposition to Assad.</p>
<p>The local and international efforts may come together in time, but the political clock is ticking, and without clear evidence of progress by next November, the Democrats are far more vulnerable to the Republicans. To put the political point in stark terms: Going into 2012, Obama had Osama. Going into 2016, the Democrats need the fall of Raqqa and Mosul.</p>
<p> </p>
<p><strong>FACED WITH THE UNCERTAIN</strong> prospects of current policy, Clinton and the Democrats should push Obama to do more and to do it faster, while continuing to develop the language of power and protection that the president employs as an alternative to the right-wing conception of national strength. In the right-wing vision of a fortress America, the United States is safer when it summons its own overwhelming power, closes itself off to refugees and immigrants, and dispenses with legal niceties such as respect for human rights.</p>
<p>The alternative language of power emphasizes strength through diplomacy and alliances, through inclusiveness at home, and through the embodiment of the values of freedom and equality in national policy. These are elements of the liberal theory of power—the idea that liberal values and institutions deserve popular support not only because they are just, but also because they are durable bases of security and strength.</p>
<p><span class="pullquote-right">The response to Islamist terrorism brings out the differences between the right-wing and liberal worldviews.</span> As many have pointed out, ISIS wants to destroy the “gray zones” in the West where Muslims live peaceably with others. When politicians on the right call for anti-Muslim measures, they are doing exactly what ISIS is hoping for. When they frame terrorism as a result of the “clash of civilizations” (as Marco Rubio did after the Paris attacks in November), they are equating Islam with ISIS. The liberal response—reassuring Muslims, distinguishing sharply between the small number of terrorists and the vast Muslim majority, and calling upon that majority to mobilize against hatred and intolerance—is also the stronger and smarter course in the struggle against terrorism.</p>
<p>To be sure, neither Obama nor any other president can prevent every terrorist act. But clear and convincing progress against ISIS abroad will give the public more confidence that the government is doing all it possibly can to stop terrorism. Contrary to the voices urging patience and containment, Obama ought to be pressing the fight to defeat ISIS’s “caliphate” with a timetable measured in months rather than years. Americans need to see progress in 2016. “Every time things gets worse, I do better,” Trump said on December 5 in the wake of the attack in San Bernardino. On that particular point, he may well be right.</p>
</div></div></div>Wed, 16 Dec 2015 10:01:58 +0000223629 at http://prospect.orgPaul StarrWe Need Clarity about ISIS, and the Democratic Candidates Didn’t Provide Ithttp://prospect.org/article/we-need-clarity-about-isis-and-democratic-candidates-didn%E2%80%99t-provide-it
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p class="embed"><span style="line-height: 1.538em;"></span></p>
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap464267356656.jpg?itok=qtnlFEwk" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Jacques Brinon</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Rescue workers gather at victims in the 10th district of Paris, Friday, November 13, 2015.</p>
</div>
</div>
</div>
</div>
<p></p>
<p class="embed"><span style="line-height: 1.538em;"><span class="dropcap">M</span>any Democrats—including the candidates for president at Saturday night’s debate in Iowa—are not registering the full import of the attacks in Paris. When French President Francois Hollande declared the massacre “an act of war” and ISIS claimed responsibility and announced that the attacks were the “first of a storm,” the conflict with ISIS entered a new stage.</span></p>
<p>In responding to the advance of ISIS in Syria and Iraq, the Obama administration has tried to rely on local proxies—Syrian moderates, Kurds, the Iraqi army—to do the fighting on the ground, while the United States has supplied air power, intelligence, equipment, and other resources. Obama’s reluctance to commit ground troops is understandable. But with clear evidence his strategy was insufficient, the president announced on October 30 that several dozen special operations forces would go into Syria.</p>
<p>Although the Kurds have recently had some success in breaking ISIS’s supply lines in western Iraq, the basic assumptions behind Obama’s original strategy have now been shattered in two ways. First, the local ground forces are too weak to defeat ISIS on anything like a reasonable timetable. And second, as the downing of the Russian airliner and the attacks in Beirut and Paris show, we can no longer assume that ISIS is focused entirely on seizing and defending territory. It is a much more direct threat to us. No one should think that because ISIS murdered Russians and Parisians first, it won’t murder Americans next on a large scale.</p>
<p>That is why the responses of Hillary Clinton, Bernie Sanders, and Martin O’Malley at the Democratic debate were so unsatisfactory. Sanders and O’Malley were out of their depth on foreign policy, but even Clinton fell short. When she said that, “it cannot be an American fight,” she may have meant that the fight against ISIS cannot <em>only </em>be an American fight, or that the United States should just provide logistical support. But to call for a multilateral effort is not enough. A presidential candidate should be clear that the United States is going to have to lead that effort, and if that effort is to succeed, it more than likely will require more American troops than the few dozen that Obama has already committed.</p>
<p><span class="pullquote-right">The proper analogy here is not to the Iraq War, but to the original response of the United States after September 11, 2001, in going into Afghanistan against the Taliban and al-Qaeda. </span>That effort was justified as self-defense, and it should have been sharply delimited, with no illusions about permanently changing Afghan society. But we could not live with a terrorist organization like al-Qaeda able to use Afghanistan as a sanctuary from which it could launch attacks.</p>
<p>So, too, we—and it is a very broad “we,” encompassing not just NATO allies, but many other countries—cannot live with ISIS launching attacks from its sanctuary. ISIS, in fact, is an especially grave threat because the territory it holds provides it with oil resources and wealth and consequently the ability to finance and organize terrorism on a far-reaching basis.</p>
<p>Of course, we should never intervene militarily in any region, least of all the Middle East, without adequate justification and a plan of action. But Syria’s civil war has now become four separate disasters: 1) the horrors being visited on the Syrian people; 2) the flood of immigrants into Europe; 3) the right-wing reaction in Europe being fed by that flood; and 4) the direct threat posed by ISIS. We have passed a threshold of justification. The plan must follow, developed in coordination with other countries.</p>
<p>Who was Hollande speaking for when he said the Paris attacks were an “act of war”? Was it just an act of war against France? Or was it an act of war against America as well? Americans ought to be clear that the war ISIS is fighting is as much against us as against the French, and we have to act accordingly. Although the wide opposition to ISIS creates an opportunity to organize a broad military coalition, the United States cannot build such a coalition while insisting that someone else—anyone else—do all the actual fighting.</p>
<p>In any event, I suspect that ISIS itself will clarify the realities. When it says the Paris attacks were the “first of a storm,” we should brace ourselves. And the Democratic candidates should be clear about what we should be prepared to do.</p>
</div></div></div>Sun, 15 Nov 2015 22:56:23 +0000223460 at http://prospect.orgPaul StarrA Shocking Rise in White Death Rates in Midlife -- and What It Says About American Societyhttp://prospect.org/article/shocking-rise-white-death-rates-midlife-and-what-it-says-about-american-society
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><span style="line-height: 1.538em;"><span class="dropcap">I</span>n a reversal of earlier trends, death rates among white non-Hispanic Americans in midlife increased sharply between 1999 and 2013, according to a new study by economists Anne Case and Angus Deaton, winner last month of the Nobel Prize for economics. The increased deaths were concentrated among those with the least education and resulted largely from drug and alcohol “poisonings,” suicide, and chronic liver diseases and cirrhosis. This midlife mortality reversal had no parallel in any other industrialized society or in other demographic groups in the United States.</span></p>
<p>Case and Deaton’s analysis, <a href="http://www.pnas.org/content/early/2015/10/29/1518393112" target="_blank">published today</a> in the <em>Proceedings of the National Academy of Sciences</em>, also shows increased rates of illness, chronic pain, and disability among middle-aged whites. The findings have important implications for American politics and public policy, particularly for debates about economic inequality, public health, drug policy, disability insurance, and retirement income. The data also suggest why much of American politics may be taking on an increasingly harsh and desperate quality.</p>
<p>The recent divergence in death rates between the United States and other rich countries is striking. Between 1979 and 1999, Case and Deaton show, mortality for white Americans ages 45 to 54 had declined at nearly 2 percent per year. That was about the same as the average rate of decline in mortality for all people the same age in such countries as France, Germany, the United Kingdom, and Sweden. (See figure below.) After 1999, the 2 percent annual decline continued in other industrialized countries and for Hispanics in the United States, but the death rate for middle-aged white non-Hispanic Americans turned around and began rising half a percent a year.</p>
<p></p><div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/mortality-figure.png?itok=4cYczmgY" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">Anne Case and Angus Deaton, “Rising Morbidity and Mortality in Midlife among White Non-Hispanic Americans in the 21st Century,” Proceedings of the National Academy of Sciences, November 2, 2015. </div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p><strong>The White Midlife Mortality Reversal:</strong> All-cause mortality, ages 45–54 for U.S. white non-Hispanics (USW), US Hispanics (USH), and six comparison countries: France (FRA), Germany (GER), the United Kingdom (UK), Canada (CAN), Australia (AUS), and Sweden (SWE).</p>
</div>
</div>
</div>
</div>
<p>The consequences of this divergence have been staggering. If the white midlife mortality “had continued to decline at its previous (1979‒1998) rate,” Case and Deaton estimate, “half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the U.S. AIDS epidemic through mid-2015.”</p>
<p>Case and Deaton’s data indicate that the white midlife mortality reversal was due almost entirely to increased deaths among those with a high school degree or less. Mortality rates in that group rose by 134 per 100,000 between 1999 and 2013, while there was little change among those with some college, and death rates fell by 57 per 100,000 for those with a college degree or more.</p>
<p>Death rates from suicide and poisonings such as drug overdoses increased among middle-aged whites at all socioeconomic levels (as measured by education). But the increases were largest among those with the least education and more than sufficient in that group to wipe out progress in reducing other causes of death. Deaths from diabetes rose slightly but did not account for a significant part of the white midlife mortality reversal.</p>
<p>None of this is to suggest that whites are generally in worse health than blacks. Among blacks, midlife mortality has been higher than among whites. But over the period 1999-2013, according to Case and Deaton, midlife mortality declined by more than 200 per 100,000 for blacks while it was rising for whites. As a result, the ratio of black to white mortality rates dropped from 2.09 in 1999 to 1.40 in 2013. Contrary to what many Americans may still believe, drug overdoses are no longer concentrated among minorities; in fact, among the 45-54 age group, drug-related deaths are now higher among whites.</p>
<p>Case and Deaton also cite evidence of declining mental and physical health among whites ages 45 to 54 between 1999 and 2013. According to national surveys, mental illness rose. There were significant increases as well in the percentages reporting poor health, chronic pain, and difficulties with such activities as walking a quarter mile, climbing ten steps, and socializing with others. The percentage reporting themselves unable to work doubled.</p>
<p>These findings suggest that something has gone deeply wrong for middle-aged white Americans—changes that have hit the less educated especially hard in the 21st century. Previous studies have pointed to rising economic pressures on low- and middle-income workers that have been especially acute for those with only a high school education. On the right, in a 2012 book, <em>Coming Apart: The State of White America, 1960-2010</em>, Charles Murray argued that a decline in moral virtue since the 1960s has led to the deterioration of life among low-income whites. For example, according to Murray, low-income whites work fewer hours than they used to and are more likely to be out of the labor force because they have abandoned the work ethic and prefer, in Murray’s words, “goofing off.” Although educated Americans in the upper-middle class have been working more and doing well, Murray contends that “they have abdicated their responsibility to set and promulgate standards.” For Murray, the ultimate cause of these developments is the adoption of a European-style welfare state, which he maintains undermines the moral virtues at the core of what he calls the “American project.”</p>
<p>To conservatives, the white midlife mortality reversal in the United States may initially seem to confirm Murray’s argument about moral decay caused by the welfare state. But that interpretation runs into an obvious objection: Similar trends are not evident in the European countries that have even more generous systems of social protection than the United States does.</p>
<p>Although Case and Deaton are cautious about interpreting the data, they single out two possible causes of the mortality reversal. The first relates specifically to the timing of increased drug-related deaths: the introduction and ready availability of opioid prescription painkillers (such as Oxycontin) beginning in the late 1990s, followed by a shift to heroin, both directly linked to rising death rates among whites over the 1999-2013 period. But it is not clear, Case and Deaton point out, whether rising drug use is a response to an “epidemic of pain,” or whether the introduction and distribution of new prescription painkillers played an independent, causal role. One way or the other, however, Case and Deaton’s study puts in bold relief the sheer magnitude of the consequences of today’s drug plague.</p>
<p>A second potential cause highlighted by Case and Deaton (and possibly related to the first) is stress from economic change resulting from slower economic growth and rising inequality. “Many of the baby-boom generation,” they note, “are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education.” But they also observe that some other rich countries have seen “even slower growth in median earnings than the United States, yet none have had the same mortality experience.”</p>
<p>Here is where the stronger systems of social protection in other countries may play a role in both reducing inequality and cushioning people from the adverse social psychological consequences of wage stagnation. One key difference potentially affecting people in midlife, as Case and Deaton point out, is that the other rich countries have maintained defined-benefit pensions, while employers in the United States have shifted increasingly to defined-contribution pensions (such as 401(k) plans) that do not provide the same degree of security. <span class="pullquote-right">As a result, many Americans with only a high-school education not only lack the skills in midlife to find good jobs or even to stay employed but also face the likelihood of destitution in old age.</span></p>
<p>These trends put new light on current debates about disability insurance and retirement policy. Contrary to those like Murray who attribute the growth in Social Security Disability Insurance to a decline in the work ethic, Case and Deaton’s data suggest that the increased number of beneficiaries reflects a real deterioration of health in middle age. Raising the Social Security retirement age may seem to be no problem for the educated and affluent who are in good health and do little physical labor, but delaying retirement poses a much bigger problem for workers who are experiencing increased burdens of pain and disability in midlife.</p>
<p>The declining health of middle-aged white Americans may also shed light on the intensity of the political reaction taking place on the right today. The role of suicide, drugs, and alcohol in the white midlife mortality reversal is a signal of heightened desperation among a population in measurable decline. We are not talking merely about “status anxiety” due to rising immigrant populations and changing racial and gender relations. Nor are we talking only about stagnation in wages as if the problem were merely one of take-home pay. The phenomenon Case and Deaton have identified suggests a dire collapse of hope, and that same collapse may be propelling support for more radical political change. Much of that support is now going to Republican candidates, notably Donald Trump. Whether Democrats can compete effectively for that support on the basis of substantive economic and social policies will crucially affect the country’s political future.</p>
</div></div></div>Mon, 02 Nov 2015 11:10:39 +0000223362 at http://prospect.orgPaul StarrFrustration Is Driving Both Parties' Voters Toward Radical Make-Believehttp://prospect.org/article/frustration-driving-both-parties-voters-toward-radical-make-believe
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even"><p><span style="line-height: 1.538em;"></span></p>
<div class="image image-large">
<div class="field-image"><img src="http://prospect.org/sites/default/files/styles/large/public/ap878937571590.jpg?itok=Oz59jcz0" alt="" title="" /></div>
<div class="field field-name-field-credit field-type-text field-label-hidden">
<div class="field-items">
<div class="field-item even">AP Photo/Cliff Owen</div>
</div>
</div>
<div class="field field-name-body field-type-text-with-summary field-label-hidden">
<div class="field-items">
<div class="field-item even">
<p>Democratic presidential candidate, Senator Bernie Sanders speaks to supporters during a campaign rally at Prince William Fairground in Manassas, Virginia, Monday, September 14, 2015. </p>
</div>
</div>
</div>
</div>
<p></p>
<p><span class="dropcap">R</span>epublican primary voters, we are told, are furious about the failure of their party’s elected leaders to deliver on their promises. Despite controlling Congress, those leaders have done nothing about illegal immigration and have failed to repeal Obamacare, defund Planned Parenthood, or prevent the agreement with Iran from going through. Fed up with career politicians and fearing dire changes in American society, the party’s rank and file have instead gravitated to candidates who have never held public office—Donald Trump, Ben Carson, and Carly Fiorina. At least, that has been the story in the early going of the presidential race.</p>
<p>On the left, there is an analogous impatience. Just as Republicans are frustrated with the Republican Congress, so progressives are frustrated with the Obama presidency. The standard measures of economic inequality show little progress. Median incomes remain stagnant. The nation and the world continue to hurtle toward a fateful reckoning with climate change.</p>
<p>To some extent, both the conservative and progressive frustrations have the same origin—limited power in a divided government. Neither side is able to get its way because neither party controls all the levers of power. But there is an additional parallel. Both conservatives and progressives say the parties’ agendas aren’t radical enough.</p>
<p>In the Republican campaign, candidates have been trying to outdo each other in radical appeals. Build a wall on the Mexican border—and the Canadian one too. Ban abortion—even in cases of rape and incest. Abolish the Department of Education. Abolish the Internal Revenue Service. Institute a flat tax—no, abolish income taxes altogether. Unilaterally abrogate the new agreement with Iran and show the Ayatollah we mean business. Send troops to Iraq again and to Syria as well.</p>
<p>The Republican primaries are a case study in a social psychological phenomenon known as “group polarization.” When people talk only with those who share their views, they tend to move toward the extremes. None of the candidates, except occasionally Ohio Governor John Kasich, dares talk like a moderate.</p>
<p>On the Democratic side, the candidates are unlikely to race to the left in a way that’s comparable to the Republican race to the right. But the idle talk about adopting single-payer health care and emulating a Scandinavian welfare state has a similar air of unreality about it. Without a total remaking of American society and politics, these ideas have no chance of being enacted outside of Vermont (which didn’t get anywhere with single-payer after initially approving it).</p>
<p>I get that Democrats need to inspire their base, but I have never found political delusions inspiring. The Republican candidates ought to provide motivation enough for Democrats to show up at the polls. In Europe, the conservative and social democratic parties may be close enough that voters see no meaningful difference between them. But in the United States, the gap between the Republicans and Democrats is cavernous.</p>
<p>It is also simply not true that the Obama presidency has failed to make good on the crucial issues of our time. The Affordable Care Act is the most significant program benefiting low-income working people to have been enacted in decades. Recent changes in taxes have been strikingly progressive. The rate on top incomes has risen from 35 percent to 39.6 percent, and capital gains taxes for high-income people have jumped from 15 percent to 23.8 percent (counting the extension of the Medicare tax to capital income that was part of the ACA).</p>
<p>Obama has also taken important steps on climate change, providing funds for research on radical innovation in energy, imposing regulations on carbon emissions from power plants, and laying the ground for progress in international negotiations.</p>
<p>The Democrats now face one political imperative above all others: holding the presidency so as to restore a liberal majority on the Supreme Court. To be sure, Democrats will have a chance to move the Court further if they also regain control of the Senate, but the presidency is the key. The next four years will likely bring at least one and possibly two retirements among the Court’s liberal justices, and if a Republican president replaces them, conservatives will be able to consolidate their majority and entrench far-right constitutional ideas.</p>
<p>If Democrats can prevent that from happening, there will come a time when they can again pass substantial liberal legislation. But it is not likely to be in the next four years because of the Republican hold on the House. Republican leaders have to control the frustration in their ranks to avoid being stuck with a reckless and unqualified presidential nominee. Democrats have to overcome the frustrations in their ranks to be able to get their voters to show up and to sustain support despite the Republicans’ likely continued power to block major legislative initiatives. It is tricky to be inspiring and realistic at the same time. We want our leaders to disregard the chains of political practicality, which they can do in exceptional circumstances like a national crisis. This is not that kind of moment. The challenge now for Democrats is to avoid getting ahead of themselves and to understand that they will be able to do a lot more in the future if they can focus on what they have to do now.</p>
</div></div></div>Mon, 05 Oct 2015 10:28:41 +0000223162 at http://prospect.orgPaul Starr